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Court Hearing Approaches in TMA Surprise Billing Lawsuit

By Amy Lynn Sorrel

Published by the Texas Medical Association  on January 28, 2022. Read the original article here.

With a Feb. 4 court hearing on the horizon, the Texas Medical Association recently reiterated its strong opposition to a part of a federal rule that medicine says unfairly favors health insurers when directing arbiters to resolve payment disputes between insurers and physicians under the federal surprise billing law. 

TMA sued federal agencies to challenge a component of the No Surprises Act rule, under which arbiters conducting the payment dispute resolutions are required to default to the “qualifying payment amount” (QPA) as the appropriate out-of-network rate. TMA says the QPA is supposed to be the median in-network rate under the law but is deflated based upon the federal agencies’ methodology. The association’s lawsuit asks the court to strike this so-called “rebuttable presumption” provision of the rule in order to align it with the law, which directs arbiters to consider a range of relevant factors. 

TMA has asked the U.S. District Court in Tyler to decide its lawsuit as soon as possible without going to trial. The hearing on that motion for summary judgment is set for this Friday, Feb. 4.   

As federal agencies weigh in on the case in defense of their rule, a court brief filed by TMA on Jan. 24 reasserts that the regulation fails to implement the No Surprises Act the way Congress wrote it, and the consequences for patients include reduced access to care and health care consolidation. 

Congress spent years working on the No Surprises Act so it would not limit patients’ access to medical services, while protecting them from surprise medical bills, says TMA President E. Linda Villarreal, MD. 

“The last thing federal regulators should do is make health care more expensive and less accessible for people when they need it, especially during a pandemic,” she said. “The courts must reject the federal agencies’ flawed approach, because it goes against the public interest and our democratic process.” 

Dozens of national and state organizations share similar concerns and have supported TMA’s legal efforts or filed their own challenges to the rule. 

TMA’s filing also rejects the federal agencies’ claims that TMA does not have standing to pursue its case. 

TMA’s lawsuit does not delay or seek to change the No Surprises Act’s patient protections from surprise medical bills, which went into effect Jan. 1.

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