The Federal Court of Eastern Texas held yet another hearing Wednesday on the two most recent lawsuits (TMA 3, TMA 4) filed by the Texas Medical Association that challenge additional provisions of the No Surprises Act implementation rules.
Previously the TMA filed two lawsuits (TMA 1 and TMA2) that addressed issues related to the qualifying payment amount (QPA), defined as the median in-network rate for an item or service and is one of several factors that certified IDR (arbitrators) entities are required to consider when resolving payment disputes between insurance companies and providers performing these items or services.
In the TMA 1 case the federal court ruled to vacate the rule that the QPA was to be presumed the rate that out-of-network providers should be paid along with the provision that instructed IDR entities to choose the IDR payment amount that was closest to the QPA. Similarly in TMA 2 the TMA challenged the rule that required IDR entities to consider the QPA more heavily than any other factor and again the Judge decided in favor of the TMA prompting a rewrite the guidelines by HHS finding in both cases the rules unfairly advantage the insurance companies.
In Wednesday’s hearing the TMA challenged the methodology insurers and third-party administrators are using to calculate the QPA which the TMA asserts is arbitrarily deflating the QPA and again asked the Judge to vacate the QPA. As a remedy the TMA requested that the QPA continue to be used temporarily to calculate a patient/members cost sharing obligation and recommended that the QPA not be considered by IDR entities in determining payment disputes between providers and insurers pending a revision to the guidance.
The TMA 4 lawsuit also heard yesterday, challenged the substantial increase in administrative filing fees for initiating the IDR process and the claim batching rules citing these rules also unfairly disadvantage providers. TMA argues the increase in filing fees is limiting the filing of lower valued claims by providers as the cost of entry is financially prohibitive.
TMA’s remedy is to revert the filing fees back to $50 and to reimburse providers that have been paying the higher amounts, specifically the incremental $300 per filing. In addition, TMA is requesting that the deadlines be waived retrospectively so that providers that did not file due to the increase could revisit those claims.
Finally, in the TMA 4 lawsuit, the TMA asked the Court to vacate the batching provision until the rules can be revised. The Judge took the arguments under advisement and will be rendering a decision in the near future. CH Revenue Management Solutions will continue to follow these cases to ascertain any procedural regulatory changes that maybe forthcoming.