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Texas Federal Judge Rules Against HHS in Surprise Billing Lawsuit

By Admin | March 31, 2022

 - 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.

TMA filed the lawsuit against HHS in October 2021, stating that the interim final rule on surprise billing, which the Biden administration released in September 2021, goes against these policies.

According to the lawsuit, the interim final rule directs IDR entities to weigh the qualifying payment amount more than the other factors when determining a reimbursement rate. Because of this provision, TMA claimed that IDR entities have been neglecting other factors and only considering the median in-network rates, resulting in lower reimbursement rates for providers.

Additionally, the Association said it feared that the IDR process explained in the interim final rule would incentivize payers to reduce their provider networks if they could...(More)

For more info please read, Texas Federal Judge Rules Against HHS in Surprise Billing Lawsuit, by Revcycle Intelligence

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