Judge Sides with Providers in Another No Surprises Act, Payer Battle

Maybe now QPAs will "pass the laugh test."

The District Court for the Eastern District of Texas’ ruling on striking down several regulatory provisions related to the qualified payment amount (QPA) calculation is yet another win for providers.

As we know, this is the third time the court ruled to set aside certain regulations pertaining to the No Surprises Act, but this ruling specifically aimed at QPA calculations will help ensure providers have a fair fight with payers.

This is important because the design of the QPA is critical to the No Surprises Act’s mission to promote lower premiums and costs, both for consumers directly for out-of-network services as well as through the arbitration process.

QPA calculations have long been said to empower insurers to significantly reduce their in-network rates or terminate in-network agreements altogether. This can artificially lower QPAs and does not reflect market rates for services. Further, payers have been accused of miscalculating the QPA, which drives payments down even lower.

In fact, providers have argued that the QPA methodology and the miscalculations have led to QPAs that “don’t even pass the laugh test” as they are so low that they are even significantly below Medicare and Medicaid payment rates.

Having a just QPA will allow providers a fair fight in the already-burdensome independent dispute resolution process.

Did you miss the news?

Last week, a Texas judge ruled to vacate several regulations relating to the No Surprises Act that set up payment dispute resolutions between certain out-of-network providers and payers, specifically, the QPA calculations.

The court specifically disallowed several regulatory provisions related to the QPA calculation, including those that could enable insurers to include in the calculation of QPAs contracted rates for services that providers have not provided, as well as allowing self-insured group health plans to use rates from all plans administered by a third-party administrator in calculating the QPA. The No Surprises Act arbitration process is currently on hold as a result of separate litigation challenging other aspects of the regulations.