Emergency medicine’s Texan brawl with regulators & insurers over the No Surprises Act
Top of the Week
Arbitration rules from the No Surprises Act will determine how much emergency medicine practices get reimbursed for care delivered to privately insured US patients. Not surprisingly, insurers have lobbied for the law to be implemented in their favor.
EM practices are fighting back. Per CMS’ Initial Report on the Independent Dispute Resolution (IDR) Process, 81% of submitted arbitration cases were for ED services. Emergency medicine firms disputed 70,071 cases from 4/15/22 to 9/30/22. The arbitration case volume in the IDR’s first five months was higher than CMS projected for the whole year.
SCP Health submitted the largest number of IDR disputes, with 32% (n=28,196). R1 Revenue Cycle Management (11%), LogixHealth (8%), TeamHealth (4%), and Envision (3%), submitted arbitration cases on behalf of emergency clinicians.
Meanwhile, the Texas Medical Association has taken the US Department of Health & Human Services to federal court three times in the last 14 months over IDR regulations. TMA won the first round, then sued again alleging that DHHS did not comply with the initial ruling. TMA’s third lawsuit claims that insurers are using illegal means to deflate the “qualifying payment amount (QPA)”, which arbitrators use to help decide appropriate reimbursement rates. TMA’s suits have been filed in the Fifth Circuit, which has a reputation for being the US’ most conservative set of federal courts.
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