Texas Medical Association files 3rd lawsuit challenging No Surprises Act

The Texas Medical Association has filed another federal lawsuit challenging the No Surprises Act, arguing in its latest suit that portions of the rule "artificially deflate the qualifying payment amount."

The TMA said in a Nov. 30 news release shared with Becker's that the challenged provisions of the rule "skew negotiations in favor health insurers so strongly that health insurers will force physicians out of insurance networks and physicians will face significant practice viability challenges, struggling to keep their doors open in the wake of the pandemic."

The TMA said its lawsuit focuses on four ways the rule unfairly deflates the QPA:

1. The group alleges the rule permits insurers to include "ghost rates" in their QPA calculations, which are contract rates with physicians and providers who do not actually provide the service in question. The TMA said this unfairly lowers QPAs, "as there is little motivation for physicians or providers to negotiate rates for services they do not actually provide."

2. The TMA argues the rule permits insurers to include rates of physicians who are not in the same or similar speciality as the physician involved in the payment dispute. 

3. The group said the rule requires insurers to use an amount other than the total payment in calculating a QPA when a contracted rate includes "risk sharing, bonus, or penalty, and other incentive-based and retrospective payments or payment adjustments."

4. The TMA alleges the No Surprises Act allows self-insured plans to "essentially opt into a lower QPA for payment disputes with physicians."

The TMA filed its first No Surprises Act lawsuit in October 2021, successfully arguing that requiring arbitrators to heavily weigh figures created by insurers conflicted with the law and provided insurers with an unfair advantage unintended by Congress. 

The group filed a second lawsuit in September, arguing the final rule "unfairly advantage health insurers by requiring arbitrators to give outsized weight or consideration to the QPA." A hearing in that case is scheduled for Dec. 20. 

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