• NSA I-Tact

  TMA II Victory!

  Posted by name on August 2, 2024 at 7:07 pm

  Fifth Circuit Rejects Surprise Billing Arbitration Pay Formula

  o Appeals court agreed with Texas district judge on regulations

  o ‘Qualifying payment amount’ at issue in closely watched appeal

  By Rebekah Mintzer / August 2, 2024 06:43PM ET / Bloomberg Law

  The Biden administration has failed to persuade an appeals court to reinstate rules making median network rates a primary consideration in deciding payment disputes under a law meant to prevent “surprise” medical bills.

  The US Court of Appeals for the Fifth Circuit in a Friday ruling upheld a lower court decision in favor of health-care providers that vacated the regulations implementing the No Surprises Act from the Departments of Health and Human Services, Labor, Treasury, and Office of Personnel Management.

  Judge Jeremy Kernodle of the US District Court for the Eastern District of Texas had ruled in 2022 that the agencies didn’t abide by the text of the health-care benefits statute in issuing requirements that arbitrators must follow in payment dispute cases between medical providers and health insurers.

  .

  The No Surprises Act, part of the Consolidated Appropriations Act of 2021, bars providers from billing patients out-of-network rates for services rendered at in-network facilities, a situation that often arises in the context of emergency care.

  The regulations at issue in the case originally brought by the Texas Medical Association, a trade group, as well as other plaintiffs in the state, implement the law’s arbitration process for resolving surprise bills from out-of-network providers at in-network medical facilities.

  The Texas Medical Association filed numerous lawsuits challenging the dispute resolution regulations, arguing they lean too much on the qualifying payment amount, which is calculated based on median network rates from health insurers.

  The providers argued that the government’s regulations could lead to payments that are too low, while groups representing employer-sponsored plans, health insurers, and patients feared that separating payment decisions from contracted network rates would lead to a rise in cost.

  The case is Texas Med. Ass’n v. HHS, 5th Cir., No. 23-40217, 8/2/24.

  To contact the reporter on this story: Rebekah Mintzer in New York at rmintzer@bloombergindustry.com

  To contact the editors responsible for this story: Laura D. Francis at lfrancis@bloomberglaw.com; Genevieve Douglas at gdouglas@bloomberglaw.com

  • This discussion was modified 8 months ago by  Cathey Wise.

  name replied 8 months ago 1 Member · 0 Replies
• 0 Replies

Log In to Reply