No Surprises Act

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On January 17, 2024, the Departments of Health and Human Services, Labor, and the Treasury (collectively, the “Departments”) and the Office of Personnel Management issued a notice that they will reopen the period for submitting comments on the proposed rule, “Federal Independent Dispute Resolution (IDR) Operations” (the “Proposed Rule”) under the No Surprises Act (the “Act”).Continue Reading Comment Period for the No Surprises Act Proposed Rule, “Federal Independent Dispute Resolution (IDR) Operations,” Will Reopen

The status of the independent dispute resolution (IDR) process under the No Surprises Act (NSA) is ever-evolving. Providers are waiting on the sidelines as cases weave their way through the court system. While the IDR process is currently on hold, it is incumbent on providers, payors, and individuals to remain vigilant and stay abreast of the forthcoming changes.Continue Reading Sheppard Mullin Webinar – No Surprises Act: Litigation Update and Recent Guidance

On August 24, 2023, the United States District Court for the Eastern District of Texas again largely ruled in favor of the Texas Medical Association and other plaintiffs (including air ambulance providers) and vacated certain regulations[1] and related guidance concerning how the “Qualified Payment Amount” (“QPA”) – one of the factors in the arbitration of out-of-network disputes – is calculated under the No Surprises Act (the “Act”).[2] The Court also vacated certain rules specific to the QPA and Federal Independent Dispute Resolution (“IDR”) process for out-of-network air ambulance services.Continue Reading Another No Surprises Act Update: Texas Court Vacates Rules and Guidance Related to the “Qualified Payment Amount”

Earlier today, the Department of Labor, the Treasury, and the Department Health and Human Services Centers for Medicare and Medicaid Services (the “Departments”) issued a new directive to Certified Independent Dispute Resolution (IDR) Entities regarding issuing payment determinations for certain pending out-of-network (OON) disputes.Continue Reading No Surprises Act Update: Certified IDR Entities to Resume Payment Determinations for Services Furnished Before October 25, 2022

On February 6, 2023, the United States District Court for the Eastern District of Texas ruled in favor of the Texas Medical Association[1] and vacated portions of the final rule adopted in August 2022 (the “August 2022 Final Rule”) that applied to the Independent Dispute Resolution (“IDR”) process created by the No Surprises Act (the “Act”). [2] The August 2022 Final Rule was adopted by the Departments of Labor, Treasury and Health and Human Services (the “Departments”) and addressed, in part, the specific factors arbitrators must consider in resolving disputes between out-of-network (“OON”) health care providers/facilities and air ambulance providers (collectively, “Providers”), and health insurance plans, under the Act. This is the second time portions of final rules for the IDR decision-making methods have been vacated by this Court as a result of litigation brought by impacted Providers.Continue Reading Another Win for Providers: Texas Federal District Court Again Vacates Independent Dispute Resolution Rule for the No Surprises Act

Executive Summary

The California Department of Managed Health Care (“DMHC”) issued a recent guidance interpreting the application of the No Surprises Act (“NSA”)—a new federal law prohibiting out-of-network healthcare providers from balance-billing patients for certain emergency and non-emergency services—in California.  Significantly, when determining which payment and dispute resolution processes will apply in a dispute regarding the value of non-contracted emergency and non-emergency services, the NSA expressly defers to existing state law which already protects patients from receiving “surprise” medical bills, as long as such state laws conform to certain requirements set forth in the NSA.  The NSA refers to such qualifying laws as “specified State law[s]”.  However, the NSA does not explicitly indicate which states’ existing balance billing laws qualify as “specified State law[s]”—rather, each state must independently review the provisions of the NSA to determine if its existing balance billing laws qualify.
Continue Reading DMHC Guidance Confirms that California Law, Not the Federal No Surprises Act, Governs Payment and Dispute Resolution Processes for Certain Out-of-Network Services Provided in California

In our November 9, 2021, blog post on the No Surprises Act (“NSA”), we discussed new consumer protections against surprise out-of-network bills. In addition to protecting insured consumers from balance billing, the NSA protects uninsured (or self-pay) individuals from many unexpectedly high medical bills. Specifically, effective January 1, 2022, a provider must furnish a self-pay patient with notice and a good faith estimate (“GFE”) of the cost of care prior to all scheduled services. This includes, among other things, a GFE of the cost of office visits, therapies, diagnostic tests, infusions, surgeries and any services reasonably expected to be provided in conjunction with such scheduled services. On December 21, 2021, the Centers for Medicare & Medicaid Services (“CMS”) issued guidance on the Good Faith Estimate and the Patient-Provider Dispute Resolution (“PPDR”) process for people without insurance or who plan to pay the costs themselves.
Continue Reading Q&A: The No Surprises Act’s Protections for Uninsured (or Self-Pay) Individuals