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AMA Toolkit Dissects Federal Surprise Billing Law

By Joey Berlin

Originally published by the Texas Medical Association on March 10, 20202.

Much of the federal government’s solution to resolve certain out-of-network billing disputes without balance billing or otherwise involving patients – known as the No Surprises Act – took effect at the start of 2022.

Among other pieces physicians must familiarize themselves with, the new federal law features an independent dispute resolution (IDR) process that was intended to let physicians and insurers both make their case for fair payment. Naturally, plenty of minutiae and arcana exists within the law, and a portion of the rules for the IDR process is under a legal challenge from the Texas Medical Association and others in organized medicine.

To help physician practices understand and navigate the new law, the American Medical Association has created a toolkit, Preparing for Implementation of the No Surprises Act. The 20-page toolkit includes information on:

  • Operational challenges physicians “will need to address immediately” to be compliant with the law’s new requirements, such as when uninsured and self-pay patients must receive a good-faith estimate of charges before they receive services;
  • What services and care fall under the rules of the No Surprises Act;
  • Timetables and requirements for the IDR process; and
  • When and how facilities and physician practices can obtain a patient’s consent to balance bill for out-of-network care at an in-network facility.

AMA says it will update the toolkit “as additional guidance is available” and will develop new resources on parts of the law not already included in the toolkit.

For additional information on the No Surprises Act, you can check out TMA’s list of resources on the law, which has both similarities and differences to Texas’ IDR law governing state-regulated health plans.

Meanwhile, TMA and others are still pushing to ensure the implementation of the law is fair for physicians seeking to get paid. In late October 2021, TMA filed suit to challenge what physicians and hospitals say is an unfair piece of the IDR process outlined in federal rules. Check future editions of Texas Medicine Today for updates on that lawsuit.

TMA Statement on U.S. District Court Decision to Grant Its Summary Judgment Motion

Find the original statement here.

Statement by Diana L. Fite, MD, Texas Medical Association (TMA) immediate past president, in response to the U.S. District Court for the Eastern District of Texas’ ruling on TMA’s motion for summary judgment in its lawsuit opposing federal regulatory agencies’ unlawful approach to dispute resolution under the No Surprises Act.

“TMA is pleased that the court granted its motion for summary judgment in its lawsuit challenging the federal agencies’ unlawful approach to resolving disputes under the No Surprises Act. This decision is a major victory for patients and physicians. It also is a reminder that federal agencies must adopt regulations in accordance with the law.  

“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. 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.”

TMA is the largest state medical society in the nation, representing more than 56,000 physician and medical student members. It is located in Austin and has 110 component county medical societies around the state. TMA’s key objective since 1853 is to improve the health of all Texans.

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.