Texas Medical Association Victory in No Surprises Act Lawsuit

On February 23, a Texas federal judge ruled that the payor provider-independent dispute resolution (IDR) process established under the No Surprises Act conflicts with the text of the legislation. In 2021, the Texas Medical Association (TMA) filed a lawsuit in Texas focusing on the emphasis during the IDR process on using the qualifying payment amount (QPA) to determine the in-network contracted rate. QPA is determined as the payor’s median contracted rate as of January 31, 2019, in the same insurance market. The concern is that, instead of producing market-rate physician payments, the QPA will generate an artificially low benchmark payment. The American Medical Association, American Hospital Association, American Academy of Radiology, College of American Pathologists, and several other entities have also either filed a lawsuit or joined an existing lawsuit regarding the same issue.

“TMA is pleased that the court granted its motion for summary judgment in its lawsuit challenging the federal agencies’ unlawful approach to resolving disputes under the No Surprises Act. This decision is a major victory for patients and physicians. It also is a reminder that federal agencies must adopt regulations in accordance with the law. This decision is an important step toward restoring the fair and balanced process that Congress enacted to resolve disputes between health insurers and physicians over appropriate out-of-network payment rates. The decision will promote patient access to quality care when they need it most and will guard against health insurer business practices that give patients fewer choices of affordable in-network physicians and threaten the sustainability of physician practices.”

Source: https://www.texmed.org/