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Texas Court Repeals No Surprises Act QPA Policy

Gavel

March 1, 2022

Originally posted on zelis.com

On Wednesday, February 23, 2022, a federal court struck down a controversial part of the Biden administration’s regulations that implement the No Surprises Act. Zelis Chief Legislative Affairs Officer Matthew Albright recently shared his thoughts in this four minute video.

 

The background and the ruling

Healthcare providers have filed several lawsuits challenging the Department of Health and Human Services’ (HHS) mediation process for providers and payers to settle disputes over certain out-of-network bills. On February 23, a federal court struck down the HHS’s controversial interpretation of a part of the federal law banning surprise medical bills.

In a recent summary judgment, the US District Court for the Eastern District of Texas sided with the Texas Medical Association, a trade association representing over 55,000 physicians. The court felt that HHS was mistaken in its decision to instruct mediators to give rates that insurers and providers contracted with in the past extra weight compared to other factors. As such, the court ruled that the sections of the No Surprises Act (NSA) Part Two Regulation that established certain considerations for the Independent Dispute Resolution (IDR) process must be repealed.

But what does that mean, exactly?

Under the court’s ruling, the arbiter now has to consider five different factors (instead of one primary factor) when deciding what proper reimbursement looks like. In short, the court’s decision hands healthcare providers a “win” when it comes to the arbitration process, as they will now have a better chance of receiving reimbursement higher than the in-network rate.

The downside? The ruling will make the arbitration process both more complex and subjective.

Read the full blog post at Zelis.com to get a breakdown of the ruling, possible industry consequences, and proposed next steps.

Also, as always, feel free to reach out to your Sapphire Representative for further details.

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