The Texas Medical Association extended its winning streak to four cases against the No Surprises Act last week when a U.S. District Court judge for the Eastern District of Texas issued his fourth ruling in favor of the association.
U.S. District Judge Jeremy Kernodle ruled that methodology insurers use to calculate the 'qualifying payment amount' — the basis for negotiations over out-of-network reimbursement — is "tilted in payers' favor. The court is now disallowing several provisions related to how the QPA is determined, including incorporating 'ghost rates' for services that radiologists and other docs do not provide," according to RadiologyBusiness.com.
"These provisions unfairly disadvantaged physicians in payment disputes with health insurers, ultimately robbing our patients of access to physicians' care," TMA President Rick Snyder said in a statement.
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If it stands, Kernodle's decision will end a status quo that allowed insurers to "game the system at the expense of community-based physician practices" and "bring the law back in line with what Congress intended for the No Surprises Act," according to the American College of Radiology.
The No Surprises Act, signed into law in 2020, "protects people covered under group and individual health plans from receiving surprise medical bills when they receive most emergency services, non-emergency services from out-of-network providers at in-network facilities, and services from out-of-network air ambulance service providers," according to the Centers for Medicare & Medicaid Services.
Related: Judge on providers' side in CMS out-of-network billing arbitration
The agency's website has been updated to note that all federal independent dispute resolution process operations have been suspended and that "disputing parties should continue to engage in open negotiation."
"[The Department of] Health & Human Services should promptly re-open the IDR process and instruct arbitrators to disregard qualified payment amount calculations until a rule that complies with the court's decision is published," Christopher S. Kang, president of the American College of Emergency Physicians, said in a statement. "We strongly support additional steps by legal and regulatory authorities to mitigate the concerted effort by insurance companies to avoid or delay payments, even after claims are adjudicated in the physician's favor."
The TMA filed this lawsuit in November 2022.
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