HIMSSCast: The entangled legal battle over the No Surprises Act

Photo: Tetra/Getty Images

The No Surprises Act, which was signed into law in 2020, and went into effect on January 1, 2022, aimed to take patients out of billing conflicts between providers and payers. By all accounts this part of the law has been successful in preventing patients from getting a surprise medical bill when they see an out-of-network physician at an in-network hospital.

But for providers and payers, the No Surprises Act has created a quagmire of questions and litigation over how the Qualifying Payment Amount is reached and more importantly, who gets to decide.

Attorney Gary Qualls, a K&L Gates Health Care partner, litigates, arbitrates and mediates healthcare disputes as a member of the firm's Health Care Payor-Provider Disputes (U.S.). In a conversation with Healthcare Finance News Executive Director Susan Morse, Qualls explains the challenges to the No Surprises Act and what providers can expect.

Talking points:

• The No Surprises Act seeks to set up a structure whereby providers and payers can work out their disputes taking patients out the middle of the process.
• In baseball arbitration under the NSA, the arbitrator cannot choose a middle ground.
• The arbitration process uses in-network contracted rates.
• Medicare and Medicaid are not covered under NSA and states have set up their own statutes.
• Interim final rules went beyond the statutory intent of the law.
• The qualifying payment amount is the payer's median contracted rate as of January 2019, adjusted forward for inflation. 
• October 2021 interim final rules set the QPA as the presumptive amount to be paid.
• The Texas Medical Association has filed numerous lawsuits.
• In February 2022, in the first court decision, the Texas federal court struck down portions that gave extra weight to QPA.

More about this episode:

Revenue cycles challenged by mandates of No Surprises Act

No Surprises Act prevented 9 million surprise bills

AHA and AMA withdraw lawsuit over enactment of No Surprises Act

HHS and federal departments issue final rules to clarify No Surprises Act dispute resolution

Texas Medical Association files another lawsuit against No Surprises Act

Texas doctors file lawsuit over No Surprises Act 600% fee hike

Twitter: @SusanJMorse
Email the writer: SMorse@himss.org