Texas Medical Association sues feds over surprise-billing rule

The Texas Medical Association has sued the Biden administration over what it says is an unfair process to resolve billing disputes between health insurers and providers. 

The lawsuit, filed Oct. 28 in the U.S. District Court for the Eastern District of Texas, claims that CMS under Biden's leadership failed to follow clear direction from Congress about implementing the dispute resolution process. 

Under the interim final rule released Sept. 30, CMS is directing the arbitrator in the independent dispute resolution process to assume that the qualifying payment amount, which is the median in-network rate set by health insurers, is the appropriate out-of-network rate. 

"This creates a bias that prioritizes offers closest to the QPA, rather than allowing arbitrators to exercise their discretion to weigh all relevant factors and select the reimbursement rate that most accurately reflects fair market reimbursement and individual circumstances," the Texas Medical Association said in a news release.  

The Texas Medical Association said it supports the patient protection intent of the No Surprises Act, but the current dispute resolution process is a "short-sighted approach" that will drive down reimbursement rates and encourage insurers to narrow their networks.

"TMA supports the patient protection intent of the No Surprises Act," said Linda Villarreal, MD, president of the Texas Medical Association. "However, TMA's lawsuit challenges one component of the administration’s rule that ignores congressional intent and unfairly gives health plans the upper hand in establishing payment rates when a patient receives care from an out-of-network physician, oftentimes in an emergency."

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