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Physicians go to court over billing dispute resolution regs in No Surprises Act

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Texas Medical Association claims arbitration rules give unfair advantage to health insurers.

Physicians are going back to court to contest rules in the federal No Surprises Act that governs payment disputes between physicians and health insurers.

The Texas Medical Association (TMA) filed the lawsuit to challenge the U.S. Department of Health and Human Services’ final rules that were published in August. In a news release announcing the lawsuit, TMA said the association is arguing the challenged provisions of the final rule deprive physicians and providers of the arbitration process that was intended in the law.

“We are, once again, asking for the law to be followed as Congress intended, and for the challenged provisions to be invalidated,” TMA President Gary W. Floyd, MD, said in a news release. “There should be a level playing field for physicians and health care providers in payment disputes after they’ve cared for patients.”

‘How is that fair?’

TMA has stated its physician members support efforts to end surprise billing that leaves patients with unexpected costs and physicians with limited access to patients and their health plans.

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The No Surprises Act aimed “to restrict surprise billing for patients in job-based and individual health plans who get emergency care or nonemergency care from out-of-network providers at in-network facilities, and air ambulance services from out-of-network providers,” according to the U.S. Centers for Medicare & Medicaid Services.

When insurers and physicians or other health care providers cannot agree on an appropriate reimbursement amount, either side may initiate an independent dispute resolution (IDR) process that proceeds “baseball-style.” Each party submits an offer and an arbitrator selects one as the payment amount, according to TMA’s complaint.

The arbitration rules favor health insurers because the rules require arbitrators to give heavy consideration to a “qualifying payment amount” (QPA) that the health insurers calculate to serve as a benchmark for patient cost-sharing under the No Surprises Act, according to TMA.

“This is unfair to physicians, providers, and the patients we care for, so we had to seek fairness,” Floyd said. The lawsuit called the rules “manifestly unlawful,” skewing results in favor of the insurers with “a windfall they were unable to obtain in the legislative process.”

“At the same time, they will undermine healthcare providers’ ability to obtain adequate reimbursement for their services, to the detriment of both providers and the patients they serve,” the complaint said

Pledging support

The lawsuit filed Sept. 22 in U.S. District Court-Eastern District of Texas comes 11 months after TMA’s first legal challenge to the No Surprises Act rules. In February, a federal judge agreed the QPA rule conflicted with the Act and that federal agencies improperly bypassed public notice and comment in implementing it.

The American Medical Association (AMA) and the American Hospital Association (AHA) announced their intention to file a court brief supporting TMA.

“The Texas court previously held that the interim final rule impermissibly rewrote clear statutory terms by placing a thumb on the scale in favor of commercial insurers. The final rule suffers from the same problems,” the associations said in a joint statement. “As was the case with the previous suit, the AHA and AMA want to see the law’s core patient protections move forward and seek only to bring the regulations in line with the law. We look forward to supporting the Texas Medical Association’s efforts to restore the balanced, patient-friendly approach that Congress passed and the AHA and AMA supported.”


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