Audits

July 11, 2024

• First audit of the No Surprises Act conducted by CMS, “Final Report: Federal Qualifying Payment Amount Audit of Aetna Health Inc.”

Letters

October 30, 2024

• Letter from the American Medical Association (AMA) in support of H.R. 9572, the Enhanced Enforcement of Health Coverage Act. AMA states that the “legislation would help enforce IDR decisions and reestablish the balance achieved in the statute. Specifically, the Enhanced Enforcement of Health Coverage Act would permit penalties on parties that do not adhere to statutory timelines for payment after an IDR entity has made a final and binding determination. This legislation is even more critical as the courts question whether parties have a private right of action to enforce an IDR determination.”

March 18, 2024

• Letter from 39 members of Congress to Secs. Becerra and Yellen and Acting Sec. Su. Among other excellent points, they write, “…[W]e continue to hear that a number of larger issues remain unresolved related to the qualified payment amount (QPA), network shrinking, compliance, and enforcement with statutorily required payment timelines.”

November 9, 2023

• Letter from House Ways and Means Committee Chairman Jason Smith and 25 other members to Secs. Becerra and Yellen and Acting Sec. Su. They write, “We cannot emphasize strongly enough the depths of the Departments’ failure to implement the No Surprises Act as written in statute and as Congress intended. We ask that you swiftly revisit the final rule, ensure that it aligns with the law as written, and take immediate steps to make the law’s transparency provisions a reality for patients.”

August 11, 2023

• Letter from Dr. Andrea Brault, chair of the Emergency Department Practice Management Association (EDPMA), to CMS Administrator Chiquita Brooks-LaSure. In it, she states, “To reduce IDR backlogs and to support timely emergency care, CMS must act with urgency to reopen the IDR process.”

August 10, 2023

• Letter from Sen. Bill Cassidy to Sec. Xavier Becerra reiterating his deep concern about how the Department of Health and Human Services (HHS) has interpreted the No Surprises Act. This comprehensive letter details 41 issues regarding the implementation of the statue and sets a deadline of September 15, 2023 for the agency to respond.

February 28, 2023

• Letter from the American College of Emergency Physicians (ACEP), American College of Radiology (ACR), and American Society of Anesthesiologists (ASA) to the Center for Consumer Information and Insurance Oversight’s (CCIIOO) Deputy Director Ellen Montz on expediting resumption of IDR entities’ (IDREs) payment determinations.

January 23, 2023

• Letter from Dr. James Madara, CEO of the American Medical Association, to Secs. Xavier Becerra, Janet Yellen, and Marty Walsh.

January 23, 2023

• Letter from the American College of Emergency Physicians (ACEP) and the Emergency Department Practice Management Association (EDPMA) to the U.S. Departments of Health and Human Services (HHS), Labor, and Treasury, outlining solutions to address the significant challenges facing emergency physicians who try to use the independent dispute resolution (IDR) process.

Decisions and Appeals

August 24, 2023

• Opinion and order from U.S. District Judge Jeremy Kernodle in Texas Medical Association (TMA), et al v. HHS, et al. (TMA III). TMA wins its fourth straight case against federal regulators. This decision vacates many portions of the Departments’ regulations and guidance governing how health insurance companies calculate the qualifying payment amount (QPA).

August 3, 2023

• Opinion and order from U.S. District Judge Jeremy Kernodle in Texas Medical Association (TMA), et al v. HHS, et al. (TMA IV). TMA wins its third straight case against federal regulators. This decision 1.) vacates the 600% increase in the independent dispute resolution (IDR) process’ administrative fee; and 2.) vacates a rule that restricted the ability to batch similar IDR claims into a single IDR process.

July 12, 2023

• Appellate brief from the Department of Justice (DOJ) appealing the TMA II decision. This decision vacated certain portions of the Interim Final Rules (IFR) Part II, which were determined to continue to prioritize the qualifying payment amount (QPA) in the federal independent dispute resolution (IDR) process.

February 6, 2023

• Opinion and order from U.S. District Judge Jeremy Kernodle in Texas Medical Association (TMA), et al v. HHS, et al. (TMA II). TMA wins its second case against federal regulators.

February 23, 2022

• Opinion and order from U.S. District Judge Jeremy Kernodle in Texas Medical Association (TMA), et al v. HHS, et al. (TMA I). TMA won this case, with the court ruling that the agencies unlawfully required arbitrators to "rebuttably presume" the offer closest to the qualifying payment amount (QPA) was the appropriate out-of-network rate.

Lawsuits

January 30, 2023

• TMA IV: Lawsuit filed by the Texas Medical Association, Dr. Adam Corley, Tyler Regional Hospital, the Texas Radiological Society, and Houston Radiology Associated against the U.S. Departments of Health and Human Services, Treasury, and Labor, the Office of Personnel Management, and the Centers for Medicare & Medicaid Services (CMS). This complaint challenges regulators’ unilateral decision to impose a sharp 600% increase in administrative IDR fees and the requirement to batch by same CPT code.

November 30, 2022

• TMA III: Lawsuit filed by the Texas Medical Association, Dr. Adam Corley, and Tyler Regional Hospital against the U.S. Departments of Health and Human Services, Treasury, and Labor, and the Office of Personnel Management. This complaint challenges certain portions of the agencies’ July 2021 interim final rules that artificially deflate health plans’ qualifying payment amount (QPA).

September 22, 2022

• TMA II: Lawsuit filed by the Texas Medical Association, Dr. Adam Corley, and Tyler Regional Hospital against the U.S. Departments of Health and Human Services, Treasury, and Labor. This complaint challenges the No Surprises Act’s final rules from the agencies in August 2022, claiming the final rules unfairly advantage health plans by requiring independent dispute resolution entities (IDREs) to give outsized weight or consideration to the plans’ qualifying payment amount (QPA).

Amicus Briefs

October 4, 2024

• Amicus brief from the U.S. government in support of plaintiffs in Guardian Flight v. Health Care Service Corporation in U.S. Fifth Circuit Court of Appeals. This brief argues for enforcement of independent dispute resolution (IDR) decisions under the No Surprises Act. The U.S. Department of Labor and U.S. Department of Justice argue that IDR awards must be judicially enforceable, ensuring compensation according to the law.

March 20, 2024

• Amicus brief from the American Society of Anesthesiologists (ASA), the American College of Emergency Physicians (ACEP), and the American College of Radiology (ACR) in the U.S. Fifth Circuit Court of Appeals. This is the organizations’ fifth amicus brief in support of the Texas Medical Association’s (TMA) suit challenging the federal government’s improper implementation of the No Surprises Act. The societies contend that significant portions of federal agencies’ July 2021 interim final rule (IFR) implementing the NSA are flawed. The brief advocates that the Fifth Circuit should uphold an earlier district court’s judgment that invalidated the final rule’s provisions, which unlawfully favor the qualified payment amount (QPA) when determining out-of-network payments.

September 18, 2023

• Amicus brief from the American Society of Anesthesiologists (ASA), the American College of Emergency Physicians (ACEP), and the American College of Radiology (ACR) in the U.S. Fifth Circuit Court of Appeals. ASA, ACEP, and ACR urge the appellate court to uphold the U.S. District Court for the Eastern District of Texas’ decision in TMA II. The brief also urges the court to consider the adverse impact of the government’s QPA rule on physician practices and patient access to needed care.

February 21, 2023

• Amicus brief from the Emergency Department Practice Management Association (EDPMA) in support of TMA IV.

February 21, 2023

• Amicus brief from the American Society of Anesthesiologists (ASA), the American College of Emergency Physicians (ACEP), and the American College of Radiology (ACR) in support of TMA IV.

January 31, 2023

• Amicus brief from the American Medical Association (AMA) in support of TMA III.

January 31, 2023

• Amicus brief from the American Society of Anesthesiologists (ASA), the American College of Emergency Physicians (ACEP), and the American College of Radiology (ACR) in support of TMA III.

January 31, 2023

• Amicus brief from the Emergency Department Practice Management Association (EDPMA) in support of TMA III.

October 19, 2022

• Amicus brief from the American Society of Anesthesiologists (ASA), the American College of Emergency Physicians (ACEP), and the American College of Radiology (ACR) in support of TMA II.

October 19, 2022

• Amicus brief from the American Medical Association (AMA) and the American Hospital Association (AHA) in support of TMA II.

December 17, 2021

• Amicus brief from Action for Health in support of TMA I.

Guidance and Updates

August 11, 2023

• FAQs regarding the independent dispute resolution (IDR) process’ administrative fees in light of the departments court loss in TMA IV.

August 4, 2023

• Unplanned outage from CMS, “As a result of the TMA IV decision, effective immediately, the Departments have temporarily suspended the Federal IDR process, including the ability to initiate new disputes until the Departments can provide additional instructions.”

July 7, 2023

• FAQs regarding implementation of certain provisions of the Affordable Care Act (ACA) and Title I (the No Surprises Act) of Division BB of the Consolidated Appropriations Act, 2021.

April 27, 2023

• Status update on the federal independent dispute resolution (IDR) process.

March 17, 2023

• Guidance document from the Department of the Treasury, Department of Labor, and Department of Health and Human Services, “Federal Independent Dispute Resolution (IDR) Process Guidance for Disputing Parties”.

Reports

December 12, 2023

• Report to Congressional Committees from the Government Accountability Office (GAO), “Roll Out of Independent Dispute Resolution Process for Out-of-Network Claims Has Been Challenging”.

July 7, 2023

• First annual report, as required by Congress, from the Department of Health and Human Services (HHS), Evaluation of the Impact of the No Surprises Act on Health Care Market Outcomes: Baseline Trends and Framework for Analysis.

Regulations

November 3, 2023

• Proposed rule, “Federal Independent Dispute Resolution Operations”.

September 20, 2023

• Proposed rule, “Federal Independent Dispute Resolution (IDR) Process Administrative Fee and Certified

  IDR Entity Fee Ranges”.

August 26, 2022

• Final rules under the No Surprises Act, “Requirements Related to Surprise Billing”, Internal Revenue Service, Department of the Treasury; Employee Benefits Security Administration, Department of Labor; Centers for Medicare & Medicaid Services, Department of Health and Human Services.