In a recent federal court decision, the United States District Court for the Eastern District of Texas held that the presumption that the QPA be the appropriate payment amount in arbitrations under the new No Surprises Act between health insurance payors and healthcare providers conflicts with Congressional intent.
The No Surprises Act (“NSA”), which went into effect January 1, 2022, grants US healthcare consumers new billing protections when receiving emergency care, non-emergency care from out-of-network providers at in-network facilities, and air-ambulance services from out-of-network providers. Specifically, the NSA aims to eliminate surprise medical billing.
In October of 2021, Government agencies published a second Interim Final Rule, outlining an Independent Dispute Resolution (“IDR”) process that out-of-network providers must follow in the event of a payment dispute with a health plan. As a part of this IDR process, each party must each submit what they believe is the appropriate reimbursement amount for the disputed service. In most cases, the arbitrator is then required to select the offer closest to the Qualifying Payment Amount (QPA). The QPA is defined as the median of an insurer’s contracted rate in the same geographic region within the same insurance market.
In Texas Medical Association & Adam Corley v. United States Department of Health and Human Services, et al., the court rejected the requirement that the QPA serve as the presumptive compensation amount in payment disputes between certain out-of-network providers and patient health plans. The court held that the NSA, “unambiguously establishes the framework for deciding payment disputes,” and that the Regulation mandating that the QPA serve as the presumptive payment amount, “conflicts with the statutory text.”
The court not only elaborates that the NSA provides arbitrators with several factors to consider, but also notes that the NSA does not, “instruct[s] arbitrators to weigh any one factor or circumstance more heavily than the others.” Ultimately, the court reasons that Congress very meticulously outlined the arbitration process.  As such, had the intent been to create a presumption, or place any varying levels of importance on the different factors identified, Congress would have done so.
Accordingly, arbitrators involved in payment disputes under the NSA must now equally consider all of the factorsoutlined in its determination of the appropriate reimbursement figure. These factors include the QPA, the training, experience and quality of the provider, the market share held by the provider or payer, the acuity of the patient, and any past network contract negotiation efforts by the parties.
For more information on how the No Surprises Act affects out-of-network provider reimbursement for services, or for representation in rate negotiations or arbitration proceedings, contact the experienced attorneys at Abril Law for a free consultation.