out-of-network

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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”

On August 3, 2023, the United States District Court for the Eastern District of Texas once again ruled in favor of the Texas Medical Association[1] and vacated portions of the guidance related to (i) the administrative fee for the Independent Dispute Resolution (“IDR”) process created by the No Surprises Act (the “Act”) and (ii) the “batching” of claims for the IDR.[2] The Department of Health and Human Services promptly announced that the IDR process is temporarily suspended and will not be available for out-of-network disputes until further notice.Continue Reading No Surprises Act Update: Federal IDR Temporarily Suspended After Court Vacates Increased Administrative Fees and Rule for Batching Claims

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

Regardless of a patient’s diligence in selecting an in-network hospital, ambulatory surgery center, or other health facility for treatment, patients are still being saddled with surprisingly high medical bills that include out-of-network rates which often dwarf the discounted in-network rates. These “Surprise Bills” occur when a patient receives treatment from an in-network facility but also receives treatment from an out-of-network physician (or other healthcare practitioner)[1] who provides services to in-network facility patients – consider an out-of-network anesthesiology group that is the exclusive physician of anesthesia services at an in-network hospital. Studies show that this and other similar scenarios are frequently played out across the Country.
Continue Reading When your Hospital-of-Choice is In-Network but, SURPRISE, your Anesthesiologist is Not: California’s AB-72 and Other State Responses to the Surprise Billing Pandemic