NSA I-Tact
If you are joining/unjoining a community, please email info@edpma.org so we can forward Outlook... View more
Judges Question Bid to Keep Surprise Medical Billing Pay Formula
-
Judges Question Bid to Keep Surprise Medical Billing Pay Formula
Bloomberg Government
Judges Question Bid to Keep Surprise Medical Billing Pay Formula
o Case challenges method of calculating key payment factor
o District court invalidated several factors of billing rule
By Lauren Clason / September 3, 2024 06:05PM ET / Bloomberg Law
A panel of Fifth Circuit judges questioned the Biden administration’s attempt to preserve a method for calculating certain health-provider rates that play a major role in surprise medical bill disputes during oral arguments Tuesday.
The case is one of a series the Texas Medical Association filed against the Department of Health and Human Services over implementation of the No Surprises Act, which shields patients from some unexpected out-of-network bills. The lawsuits focus on the arbitration process between medical providers and insurance companies, which has also been the subject of a wave of private litigation.
The sharpest questions for the administration came from Judge Catharina Haynes, who zeroed in on how the administration defined a “bill” that marks the start of a 30-day deadline for an insurance plan to respond to a claim.
The administration defined a bill as a “clean claim,” using an industry term for bills that are considered to be accurate and complete. Air ambulance companies, part of the plaintiffs, argue the definition further delays payment because insurers can drag out the process and block them from initiating arbitration.
“We don’t tend to just run around changing words that the Congress has written,” Haynes said.
In August 2023, US District Court for the Eastern District of Texas Judge Jeremy Kernodle invalidated the method for calculating the median in-network rate—also known as the qualifying payment amount—a key factor in arbitration decisions. Kernodle also struck down guidance from the Centers for Medicare and Medicaid Services that instructed arbitrators to include the QPA as a primary factor in their decisions. The Fifth Circuit affirmed that decision last month.
The district court ruling invalidated a major component of the QPA methodology that included so-called “ghost rates,” or negotiated rates in place with a given provider but never used. Those include rates for providers who do not offer the service, TMA argued, and are therefore irrelevant and artificially lower the payment threshold.
The administration argued that TMA’s concern is satisfied by other requirements that the rate be based on those offered by similar providers in the same geographic region.
Air ambulance plaintiffs led by LifeNet Inc. urged the Fifth Circuit to uphold the district court’s rejection of a provision that excluded one-off agreements from the QPA calculation. Lawyer Stephen Lee Shackelford Jr. argued the rule omits the majority of air ambulance agreements that existed in 2019, which serves as a benchmark for rate calculations.
“If those aren’t included, then it’s hugely distorted,” he said.
The Texas Medical Association is represented by Sidley Austin LLP. LifeNet is represented by Susman Godfrey, L.L.P.
The case is Texas Med. Ass’n v. HHS, 5th Cir., No. 23-40605, oral arguments 9/3/24.
To contact the reporter on this story: Lauren Clason in Washington at lclason@bloombergindustry.com
To contact the editor responsible for this story: Alex Ruoff at aruoff@bloombergindustry.com
Out of Network + Surprise Billing News Edit this alert
Copyright © 2024 Bloomberg Industry Group All Rights Reserved.
Manage Your Subscription
Report issue with this alert
Privacy Policy
Terms & Conditions
-
0 Replies
Sorry, there were no replies found.
Log in to reply.