Judges in the Fifth Circuit Court of Appeals upheld a 2023 ruling that the federal government’s regulations implementing the independent dispute resolution (IDR) process under the No Surprises Act improperly weighted the qualifying payment amount (QPA) during determinations.
In February 2023, a district court judge ruled in favor of the Texas Medical Association in a lawsuit against the U.S. Department of Health and Human Services. The lawsuit argued that a provision in the No Surprises Act final rule unfairly favored insurance companies. The Texas Medical Association claimed that during payment disputes between providers and insurance companies, under the final rule, independent arbitrators would first consider the insurer-set QPA when deciding a payment amount for providers. The court agreed with the Texas Medical Association, concluding that the final rule favors the QPA “by requiring arbitrators to begin with the QPA and then imposing restrictions on the non-QPA factors that appear nowhere in the statute.”
In an Aug. 6 ruling of an appeal to this decision, the Fifth Circuit Court judges ruled in favor of the Texas Medical Association and confirmed the framework conflicted with the goals of the No Surprises Act. According to the College of American Pathologists (CAP), the IDR process will therefore continue in its current form, without weighting the QPA more heavily than other factors. Future rulemaking is expected on this issue, according to the CAP.
Sources:
https://www.cap.org/advocacy/latest-news-and-practice-data/august-13-2024#story4
https://www.ca5.uscourts.gov/opinions/pub/23/23-40217-CV0.pdf
