An NSA IDR arbitration award is legally binding, but insurers don’t always pay on time. If an insurer fails to pay, healthcare providers can escalate through CMS complaints, regulatory enforcement, and, in some cases, litigation to recover the awarded amount.
At Kotlar Cohen, we help providers navigate the complex IDR process, including helping you get paid what you’re owed after arbitration. If you’re delaying with delayed payments or insurers who don’t get back to you, contact our NSA attorneys today.
Winning IDR Is Not the End
You won the arbitration. The arbitrator reviewed the evidence, chose your offer, and issued a binding decision. Under the No Surprises Act, the insurer must pay within 30 days.
At that point, most providers assume the process is over. For many, however, it’s when a new problem begins. Payment doesn’t arrive, or it arrives late. Sometimes, it comes in lower than the awarded amount.
And suddenly, you’re not longer dealing with arbitration—you’re dealing with enforcement. Unfortunately, this issue isn’t rare. A 2023 survey found that insurers only pay about 52% of NSA arbitration awards on time or in full. Insurers, including Aetna, Cigna, and United, have faced enforcement actions.
In New Jersey Horizon BCBSNJ is the largest health insurer in New Jersey, and part of the broader Blue Cross Blue Shield (BCBS) Association network. Providers across many specialties have filed hundreds of lawsuits trying to collect IDR awards. Some are even trying unsuccessfully to force payment through the courts. Horizon’s strategy is to challenge IDR awards after they’re issued, claiming cases were not eligible for federal IDR. They have also been known to use administrative review processes to delay payment timelines.
In other words, nearly half of the providers who win still have to fight to get paid. This guide explains why that happens and what you can do about it.
Why Insurers Delay or Refuse to Pay IDR Awards
The law requires payment, but enforcement is limited. Under the No Surprises Act:
- IDR decisions are final and binding
- The losing party must pay within 30 days
That part is clear. What’s less clear, and more frustrating, is what happens when insurers don’t follow through. The law establishes the obligation to pay, but it doesn’t provide a simple, automatic way to enforce that obligation.
Common Reasons Insurers Don’t Pay
In practice, payment delays and failures happen for a range of reasons. Some are administrative, slowing things down due to processing delays, internal review, or approval issues.
Other delays are more strategic:
- Disputes over whether the claim was eligible
- Arguments that the award was not properly received
- Partial payments that fall short of the decision
There are also documented cases where insurers have failed to pay or only partially paid millions of dollars in IDR awards.
The core problem is structural. The NSA created a system to resolve disputes, but not a strong system to force compliance after a decision. That gap is where many providers get stuck.
What Happens If an Insurer Doesn’t Pay an IDR Award?
If the insurer doesn’t pay within 30 days, they’re out of compliance with federal law. It doesn’t mean payment automatically follows, however. There is no built-in mechanism that forces immediate payment, automatically penalizes delay, or transfers funds without further action.
Winning IDR gives you a binding decision, but it doesn’t guarantee immediate payment. At this point, the process shifts. You are no longer proving what you’re owed. You are trying to collect what you’ve already won.
Your Options to Enforce an IDR Arbitration Award Against an Insurer
Once an insurer fails to pay an IDR award, the process shifts from arbitration to enforcing an IDR arbitration award against an insurer. At this stage, there isn’t a single, automatic solution. Instead, providers typically have a few different paths they can take, each with its own timeline, level of effort, and likelihood of success.
Option 1: File a Complaint with CMS
The primary enforcement path under the No Surprises Act is administrative. Providers can file a complaint with the federal government, specifically through agencies responsible for enforcing the law.
If you choose this option, it involves:
- Submitting a complaint through the NSA enforcement channels
- Providing documentation of the IDR decision
- Showing that payment was not made within the required timeframe
The Centers for Medicare & Medicaid Services (CMS), along with other federal agencies, has the authority to investigate and enforce compliance. Courts have repeatedly pointed providers toward administrative enforcement as the primary remedy.
This process can be effective, but it’s not fast. Investigations take time, and there’s no immediate payment guarantee. Outcomes depend on agency action as well.
Option 2: Escalate Through Regulatory Pressure
Beyond filing a complaint, providers can escalate issues when there is a pattern of nonpayment:
- Repeated complaints
- Documentation of multiple unpaid awards
- Highlighting systemic issues with a specific insurer
There is growing regulatory attention on this issue. Industry groups and policymakers have acknowledged that insurers failing to pay IDR awards is a widespread problem, prompting proposed legislation to impose penalties for nonpayment.
If an insurer consistently fails to pay, the issue may attract broader regulatory scrutiny, and enforcement actions may become more likely. Like the first option, it’s not immediate.
Option 3: Consider Litigation (When Appropriate)
Many providers ask a simple question: Can I sue the insurance company for not paying the NSA arbitration award? The answer is: sometimes, but it’s complicated.
Courts are currently divided on whether providers can bring lawsuits to enforce an IDR arbitration award against an insurer. Some courts have allowed enforcement actions, but others have ruled that the NSA doesn’t provide a private right of action.
More recently, the legal trend has shifted toward limiting private enforcement, with courts emphasizing that enforcement should go through federal agencies.
What could this option mean for healthcare providers?
- Litigation may still be possible in certain cases
- Outcomes depend heavily on jurisdiction
- Legal strategy must be carefully evaluated
Litigation is not the default path, but it can be part of a broader enforcement strategy when used correctly.
Why Enforcement Is So Challenging Under the NSA
The law prioritizes dispute resolution, not collection. The No Surprises Act was designed to solve one specific problem: how to determine what insurers should pay for out-of-network care. In that respect, it’s very detailed. The IDR process clearly defines:
- How disputes are initiated
- How evidence is submitted
- How arbitrators make decisions
Once a dispute reaches arbitration, the system is structured and predictable. That structure largely stops once a decision is issued, however.
Where the Gap Exists
The law requires insurers to pay within 30 days, but it doesn’t create a fast, direct mechanism to force payment if they don’t.
Instead, enforcement is handled separately—primarily through federal agencies like CMS, which investigate complaints and determine whether violations occurred. Because enforcement is not immediate or automatic, payment timelines can stretch beyond 30 days, and some awards require multiple follow-ups. The burden shifts back to the provider after arbitration.
High Volume Creates System Friction
The number of IDR disputes has grown rapidly in recent years. With millions of disputes filed, the system is under pressure, which affects both arbitration and post-arbitration outcomes.
In addition, insurers know enforcement isn’t immediate. They also know that providers may not pursue every unpaid award, and delays reduce pressure to pay quickly. It’s not difficult to imagine that there are cases of the insurance company not paying the NSA arbitration award.
When Should You Take Action?
Not every delayed payment turns into a full enforcement issue. In some cases, insurers process payments late due to administrative backlog or internal review cycles. A short delay, especially early in the 30-day window, may resolve on its own with minimal follow-up.
The challenge under the No Surprises Act is that delays aren’t always temporary. There’s no automatic enforcement mechanism that steps in when payment is late. As a result, the responsibility falls on you to recognize when a delay is becoming a pattern, and when it’s time to act.
How to Evaluate the Situation
Before escalating, it helps to step back and assess what you’re dealing with. Ask these questions:
- Is this a one-off delay, or part of a broader pattern?
- Has the insurer acknowledged the award and payment obligation?
- Are you receiving partial payments or no communication at all?
These details matter because they can determine whether a simple follow-up is enough or whether formal enforcement steps are necessary.
Clear Signals It’s Time to Escalate
While every situation is different, there are consistent indicators that you’ve moved beyond a normal delay. You should consider enforcement action if:
- Payment has not been received within 30 days. The insurance company is not paying the NSA arbitration award. At this point, the insurer is out of compliance with federal requirements.
- Payment is incomplete or inconsistent with the award. Partial payments can be just as problematic as nonpayment.
- Communication breaks down. If the insurer is unresponsive or unable to provide a clear timeline, that’s a red flag.
- There is a pattern of delays across multiple claims. This often signals a systemic issue rather than an isolated one.
- The amount at issue justifies escalation. Higher-value awards typically warrant more immediate action.
Why Timing Matters
Delays don’t just affect cash flow; they make enforcement harder over time. What happens the longer a claim goes unresolved?
- It becomes harder to track communications and documentation
- It’s more likely to get lost in administrative processes
- There’s less pressure on the insurer to act quickly
At the same time, federal data shows that enforcement relies heavily on complaints and follow-up, with regulators receiving thousands of NSA-related complaints and recovering millions in restitution through investigations. Action is often required to trigger enforcement. If the insurance company is not paying the NSA arbitration award, you need to act quickly.
You don’t need to escalate every delay immediately, but you do need to monitor closely and act decisively when the situation crosses from a short delay to noncompliance.
How Kotlar Cohen Helps Providers Enforce IDR Awards
Most firms focus on helping providers win arbitration, but as many providers discover, winning is only part of the problem. Getting paid is a separate challenge—and often a more difficult one.
Kotlar Cohen takes a different approach. We’re not a billing service or administrative vendor. We’re a trial-focused law firm with decades of experience handling complex disputes, including insurance payment conflicts.
- Founding partners Adam Kotlar and Justin Cohen are both certified by the Supreme Court of New Jersey in workers’ compensation law, and Adam Kotlar is also certified in civil trial law, a distinction held by only a small percentage of attorneys.
- Our firm has nearly 30 years of experience advocating for clients in high-stakes disputes and recovery matters.
That background matters in the NSA context, where enforcement often requires more than just submitting forms.
Focused on Recovering What Insurers Withhold
Kotlar Cohen’s work with healthcare providers is built around one core issue: Insurers underpay, delay, or refuse to pay, leaving providers to chase revenue.
We step in to handle that process from a legal and strategic standpoint. We:
- Challenge improper reductions and denials
- Pursue payment through administrative and legal channels
- Apply pressure where insurers rely on delay or technical defenses
This same approach carries over into IDR award enforcement. When an IDR award goes unpaid, our attorneys help providers move from arbitration into enforcement.
Our assistance could include:
- Evaluating whether an unpaid award is suitable for escalation
- Preparing and managing CMS complaints and regulatory follow-up
- Coordinating enforcement strategy across multiple claims or payers
- Advising on when litigation or alternative legal strategies make sense
In situations where insurers repeatedly delay or refuse payment, enforcement often requires a coordinated approach rather than a single action.
Supporting Providers in Getting What They’re Owed
Enforcement is not just administrative. It requires:
- Understanding how federal agencies actually respond to complaints
- Knowing how insurers operate within the system
- Building documentation that supports escalation
- Applying pressure at the right time; not too early, not too late
Without that, even a strong arbitration win can stall. As more providers are experiencing, unpaid IDR awards are not the exception; they’re becoming part of the process.
We step in at the point where most providers lose leverage. We help bridge the gap between winning the dispute and actually collecting the payment.
Kotlar Cohen handles that process, so your team doesn’t have to divert time and resources away from patient care or core operations.
Conclusion: Winning Is Step One. Getting Paid Is Step Two.
The No Surprises Act changed how payment disputes are resolved. It gave providers a clear path to challenge underpayments and, in many cases, providers are winning those disputes at a high rate.
However, as more providers are discovering, the process doesn’t always end there. Even after a binding arbitration decision, providers can experience:
- Delayed payments
- Partially unpaid awards
- Enforcement that requires additional steps
Federal data confirms that this is not an isolated issue. Regulators have already received thousands of complaints related to late payments and noncompliance and have had to intervene to recover millions in restitution.
The system determines what you’re owed, but it doesn’t always ensure you receive it. If an insurer has failed to pay your IDR award, you don’t have to navigate the enforcement process on your own. Contact our NSA attorneys today so we can help you move from winning arbitration to actually getting paid.