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The No Surprises Act (NSA), enacted in December 2020, was designed to protect patients from unexpected medical bills for emergency services and certain non-emergency services provided by out-of-network providers.  A central component of the NSA is the Qualified Payment Amount (QPA), which serves as a benchmark and is one of several factors for determining reimbursement […]

Nearly three years after the No Surprises Act (“NSA”) became effective, there have been many surprises along the way. From the four lawsuits by the Texas Medical Association challenging the implementation of the Act, revisions to rules put forth by the Departments and several pauses along the way, the NSA has certainly had a bumpy […]

Last week, the U.S. Fifth Circuit Court of Appeals held that regulations implemented by the Departments of Health and Human Services, Labor, and Treasury were permitted to include “ghost rates”—contracted rates for services that were never actually provided—in calculating the Qualifying Payment Amount (QPA) under the Federal No Surprises Act (NSA). This was the last […]

Late on Friday, August 2, the Fifth Circuit Court of Appeals upheld a crucial ruling in the Texas Medical Associations (TMA) II lawsuit, marking another substantial victory for out-of-network providers and the TMA.  This landmark decision affirms that the Departments (DOL, TREAS and HHS) do not have the authority to establish “substantive standards for the […]

On May 22, U.S. Senators Ron Wyden (D-OR), Chair of the Finance Committee and Bernie Sanders (I-VT) Chair of the Health, Education, Labor and Pensions (HELP) Committee issued a letter to Travis Dalton, CEO of MultiPlan.  Mr. Dalton is being called upon to address the findings from an investigation by a New York Times (NYT) […]

Last Sunday the New York Times published two articles written by journalist Chris Hamby, regarding Multiplan and the major health insurance companies. His investigation exposed the “Percentage of Savings Model”, used by Multiplan and insurers that incentivizes the parties to under-reimbursement out-of-network claims to yield higher fees for themselves: Insurers Reap Hidden Fees by Slashing […]

As previously reported, the Texas Medical Association (TMA) filed a series of lawsuits over the rules implemented by the Departments under the No Surprises Act. On August 3, 2023, Judge Kernodle, US District Court of Eastern Texas, ruled in favor of the TMA vacating certain portions of the No Surprises Act final rule. This lawsuit […]

In a recent development surrounding the implementation of the No Surprises Act (NSA), the United States Department of Justice (DOJ) has filed an appellate brief to appeal the Texas Medical Association (TMA) II decision. This decision vacated certain portions of the Interim Final Rules Part II which were determined to continue to prioritize the qualifying […]

In an effort to promote equal access to healthcare and coverage, the New Jersey Department of Banking and Insurance has published Bulletin No. 23-05 following Governor Murphy’s issuance of Executive Order 326, “Protecting Gender-Affirming Health Care in New Jersey”. This bulletin serves as a reminder to all insurance companies authorized to issue health benefits plans, […]

This week, a Texas US Federal District Court granted a summary judgement in favor of the Texas Medical Association (TMA) setting aside and vacating the latest qualifying payment amount (QPA) Rule as violating the No Surprises Act (NSA).  The Court acknowledged, “although the Departments have abandoned the ‘rebuttable presumption’ term, they have not relinquished their […]

Late Friday afternoon on December 23, 2022 and well after most had begun celebrating their holiday, CMS quietly announced that it was increasing the non-refundable administrative fee for all IDR filings initiated under the No Surprises Act from $50 per item or service to $350 per item or service commencing January 1, 2023. The fee […]

On Wednesday, November 30, 2022 the Texas Medical Association (TMA) filed its third lawsuit against the Departments of Health and Human Services, Labor and the Treasury (the “Departments”) claiming that the final revised rule under the No Surprises Act (NSA), a federal law that aims to protect patients from surprise medical bills, continues to unfairly […]