TMA's Legal Fight Under The No Surprises Act: What's Next for Providers?

The Texas Medical Association (TMA) continues to lead the charge for fair implementation of the No Surprises Act (NSA), ensuring out-of-network providers receive the compensation they deserve. In their third lawsuit challenging federal rules on qualifying payment amounts (QPA), TMA achieved critical victories while facing ongoing hurdles. The recent appellate court decision reflects both progress and persistent challenges for providers navigating the arbitration process.

At HaloMD, we’re closely tracking these developments because the outcomes directly impact how providers approach the Independent Dispute Resolution (IDR) process. These rulings offer both opportunities and challenges for healthcare professionals committed to achieving fair reimbursement.

A Split Outcome: Key Wins and Challenges

TMA challenged four provisions of federal rules that, they argued, deflate the QPA in ways Congress never intended under the NSA. In August 2023, the U.S. District Court for the Eastern District of Texas ruled in favor of TMA on all four issues. However, the U.S. 5th Circuit Court of Appeals recently upheld two of the provisions in a split decision.

The Wins:

1. Specialty Alignment: Arbitrators must consider only rates from providers in the same or similar specialty, ensuring fairer benchmarks for reimbursement.
2. Blocking Plan Manipulation: Self-insured plans cannot cherry-pick rates from other plans to artificially lower QPAs.

These rulings are critical in protecting the integrity of the arbitration process and ensuring the QPA reflects accurate market rates.

The Challenges:

1. Inclusion of Ghost Rates: The court upheld the inclusion of rates for services that haven’t been performed, potentially skewing QPA values.
2. Exclusion of Bonuses: Incentive payments, including risk-sharing arrangements, are excluded from QPA calculations, limiting fair reimbursement opportunities for providers.

Additionally, the court upheld limited disclosure requirements for QPA calculations, leaving providers with little insight into how these figures are determined.

Implications for Providers

While the wins mark progress, the remaining challenges highlight the need for vigilance and adaptation. For providers, the inclusion of ghost rates and the exclusion of bonuses create hurdles that can affect financial sustainability. Transparency remains a significant concern as providers are left navigating reimbursement frameworks with limited visibility.

HaloMD is here to help. By leveraging advanced analytics, industry expertise, and a proven track record in IDR, we empower providers to secure optimal outcomes despite these obstacles.

Advocacy Moving Forward

TMA has 45 days to determine whether to pursue an en banc review on the ghost rates and bonus exclusions. Regardless of the decision, this case underscores the importance of ongoing advocacy for fair implementation of the NSA.

At HaloMD, we applaud TMA’s dedication to defending providers and patients alike. Their leadership in these lawsuits has been instrumental in shaping a more balanced healthcare system.

Stay Informed

The evolving regulatory landscape means staying informed is critical. For a detailed overview of TMA’s efforts, visit Texas Medical Association.

At HaloMD, we’re committed to providing actionable insights and tailored solutions for providers navigating the IDR process. Visit our Insights Hub to learn more about how we can help you achieve fair and sustainable reimbursement. Together, we can meet the challenges of the NSA head-on.

Alla LaRoque is the President and Founder of HaloMD, a leader in Independent Dispute Resolution through the No Surprises Act.