A federal appellate court has affirmed a lower court ruling that the manner in which federal regulations tell No Surprises Act dispute arbiters to evaluate competing fee claims unfairly favors health care payers over providers.
At issue is a regulatory directive that arbiters weigh what is known as the qualifying payment amount – the median of what insurers contract to pay providers in a given geographic area – when deciding on payments. In February a federal court ruled that using this measure in what is known as the independent dispute resolution process unfairly stacked the arbitration process in favor of payers and ordered the discontinuation of mandatory use of the qualifying payment amount when adjudicating payment disputes. Now, a federal appeals court has upheld that earlier decision in a case filed by the Texas Medical Association.
In the past the Centers for Medicare & Medicaid Services has stayed the independent dispute resolution process in response to court rulings but it is not clear at this time whether it will do so in the wake of this latest ruling.
The No Surprises Act was passed in 2020 to help protect consumers from unexpected medical bills, especially from out-of-network providers. Disputes over such bills, previously between providers and their patients, are now addressed instead between providers and health insurers.
Learn more about the latest court ruling affecting implementation of the No Surprises Act from the appeals court decision in the case and from the Healthcare Dive article “Appeals court hands providers latest win in No Surprises litigation.”