A federal judge in Texas has ruled in favor of the Texas Medical Association (TMA) in a surprise billing lawsuit, affirming that sections of the HHS interim final rule on surprise billing violate the policies presented by Congress in the No Surprises Act.
US District Court Judge Jeremy Kernodle granted TMA’s motion for summary judgment and denied the request from HHS for a cross-motion summary judgment.
“This decision is an important step toward restoring the fair and balanced process that Congress enacted to resolve disputes between health insurers and physicians over appropriate out-of-network payment rates,” Diana Fite, MD, immediate past president of TMA, said in a statement.
“The decision will promote patient access to quality care when they need it most and will guard against health insurer business practices that give patients fewer choices of affordable in-network physicians and threaten the sustainability of physician practices.”
The lawsuit centered on the No Surprises Act’s arbitration process for resolving payment disputes between out-of-network providers and payers.
If a provider and payer cannot agree on a payment rate for a surprise bill, they must go through an independent dispute resolution (IDR) process. In an IDR process, an IDR entity determines the final out-of-network reimbursement rate for the service.
The No Surprises Act states that IDR entities should consider several factors when determining a rate, including the qualifying payment amount—a payer’s median in-network rate for the service—the provider’s level of training and experience, the difficulty of the service, and if the provider or payer attempted to enter into a network agreement.