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Last Friday, the Defendants in the lawsuit filed by the Texas Medical Association (TMA) against the U.S. Department of Health and Human Services (HHS) and other Federal Departments, entered a notice that the federal departments collectively intend to file an appeal with the United States Court of Appeals Fifth Circuit to challenge the summary judgement […]

The California Department of Managed Healthcare (DMHC) on March 21, 2022 issued an All Plan Letter with guidance to All Full-Service Commercial Health Care Service Plans clarifying the enforcement rules that apply between relevant, specified state laws, primarily AB72 and the Knox-Keene Act, and the Federal No Surprises Act (NSA). Implementation of the Federal NSA […]

Recently the U.S. Department of Labor issued a memorandum notifying the public and interested parties that the Qualifying Payment Amount (“QPA”) “presumption” has been invalidated as the result of a Federal Texas Court’s decision in a complaint filed by Texas Medical Association (“TMA”) et. al., against U.S. Departments of Health and Human Services HHS and […]

On February 23, 2022, a Federal Court in Texas issued a decision and final judgment that certain parts of the Interim Final Rules Part II (“Rules”) adopted under the No Surprises Act (“NSA”) are invalid.  Specifically, the Judge held that the “presumption” that the Qualifying Payment Amount (QPA) is the appropriate out-of-network rate, unless credible […]

The federal No Surprises Act (NSA) became effective January 1, 2022. The law is designed to protect patients from unexpected medical bills arising from emergency and most non-emergency services administered by out-of-network providers in certain settings, and it prohibits providers from balance billing patients under these circumstances.  It also protects patients from paying more than […]

The No Surprises Act (NSA) took effect January 1, 2022.  This Federal legislation requires out-of-network providers to navigate new rules and adhere to specific timeframes in order to protect their rights to challenge under-reimbursed or denied claims subject to the NSA through negotiations and the Independent Dispute Resolution process. The healthcare industry unanimously agrees that […]

As we welcome in 2022, the much-anticipated federal legislation, the No Surprises Act, has officially gone into effect to protect patients from surprise bills when receiving certain medical services mainly emergency care and non-emergency care services from out-of-network providers at in-network facilities unless notice and consent is obtained prior to the services being rendered. The […]

The NY Department of Financial Services (DFS) recently announced it is amending the NY surprise billing law to “apply federal requirements to the NY IDR process.” As previously reported, in 2020, Congress adopted the No Surprises Act (NSA) which becomes effective for plan years starting on or after January 1, 2022. Under the NSA, out-of-network providers […]

What is the Qualified Payment Amount (QPA) and why is there so much controversy surrounding the interim rules announced by the departments with regard to its application in the Independent Dispute Resolution (IDR) process under the No Surprises Act? As previously written about, the No Surprises Act (NSA) goes into effect for virtually all health […]

As previously indicated, several lawsuits have been filed challenging the rules under the No Surprises Act regarding the presumption for Independent Dispute Resolution (arbitration) that the Qualified Payment Amount (QPA), the median in-network contract rate, is the proper reimbursement for out-of-network services covered under the No Surprises Act. On December 9, 2021, a new lawsuit […]

Concerns About the Federal No Surprises Act: Interim Final Rules According to an article published by KHN, the federal agencies responsible for issuing the regulations for the implementation of “the No Surprises Act” (NSA) have publicly acknowledged that the concerns raised by legislators, providers and medical associations over the federal legislation have been heard. However, […]

For years, insurance companies have operated networks of physicians and facilities which they pair with company benefit plans and their own insurance policies to facilitate “in-network” coverage for members.  Physician networks are marketed by insurance companies to providers on the basis that joining a network will bring increased volume to the practice at a discount […]