By Chris Myers, CEO of No Surprise Bill
The No Surprises Act, designed to protect patients from unexpected out-of-network medical bills, has faced its fair share of hurdles since its inception in 2020. Now, an appeals court is presenting a rare but significant opportunity for healthcare providers to challenge the law’s arbitration process. The 5th Circuit Court of Appeals has agreed to rehear a case involving the Texas Medical Association (TMA), potentially undoing a decision made last year that sided with the federal government.
The heart of the dispute revolves around how insurers calculate the "qualifying payment amount" (QPA)—a key figure used to resolve payment disagreements between insurers and out-of-network providers. Providers argue that insurers are deliberately lowering these QPAs to favor their own reimbursement offers during arbitration, which could unfairly tip the scales in their favor.
This case represents the latest in a series of legal battles initiated by the TMA to challenge the way the No Surprises Act is implemented. Providers are particularly concerned about how QPAs are calculated and the weight these figures hold in arbitration decisions. The TMA claims that insurers are using inflated or ghost rates—prices for services not actually provided—in QPA calculations, which diminishes the fairness of the process.
What makes this case particularly significant is the rarity of rehearings granted by the 5th Circuit. The original decision, handed down last October, sided with federal agencies. However, with a majority of 5th Circuit judges voting to rehear the case, providers are now presented with a rare opportunity to present their arguments again, potentially shifting the course of the dispute resolution process.
The TMA, which has filed multiple lawsuits challenging the No Surprises rules, has voiced optimism about the court’s decision. They argue that insurers' practices undermine the intent of the law, which was supposed to shield patients from financial harm due to surprise medical bills, not provide insurers with an advantage in payment disputes.
Though the future of the case remains uncertain, the outcome of this rehearing could have wide-reaching implications for the No Surprises Act. Providers, who have long argued that the current system unfairly favors insurers, may find themselves in a stronger position if the court sides with them. However, the challenges posed by the TMA's ongoing litigation and the backlog in arbitration determinations highlight the ongoing tensions between providers and insurers over the implementation of the law.
As this case progresses, it will serve as an important reminder that the fight for fair payment practices in healthcare is far from over. Whether or not this appeals court decision will ultimately favor providers, one thing is clear: the No Surprises Act remains a battleground, with significant stakes for both the healthcare industry and the patients it serves.
