In an important victory for physicians, a U.S. District Court sided with the Texas Medical Association (TMA) in a second lawsuit regarding implementation of the dispute resolution process under the No Surprises Act. The court found that the administration’s most recent Aug. 2022 final rule once again surpassed the legal confines of the “unambiguous” statute by attempting to make the qualifying payment amount (QPA) (i.e., a health plan’s median contracted rate) the preeminent factor considered in payment disputes. This latest rule attempted to do so primarily by imposing heightened scrutiny in the non-QPA factors, creating additional procedural hurdles to consider that information and attempting to supersede arbitrators’ discretion, none of which were included or insinuated in the original statute.
In the ruling, the court notes that the August final rule made certain language revisions because of prior lawsuits, but “never relinquished their goal of privileging the QPA, tilting arbitrations in favor of insurers, and thereby lowering payments to providers.” The ruling ultimately strikes the challenged sections of the rule and remands them back to the Departments of Health and Human Services, Labor and Treasury “for further consideration in light of this opinion.” The AMA and AHA filed an amicus brief (PDF) in mid-October supporting TMA’s lawsuit.
“As this is the second time the dispute resolution rules have been vacated and remanded back to federal agencies for further consideration, the AMA urges officials to bring the regulations in line with the Act,” stated AMA President Jack Resneck Jr., MD, following the court’s decision. “Arbitrators must be able to settle billing disputes between providers and health insurers without having their hands tied by misguided rules that conflict with the letter of the law.”