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Federal Judge Strikes Down Key Portion of Surprise Billing Rule

A federal court in Texas on Feb. 23 invalidated a small portion of the Requirements Related to Surprise Billing, Part 2 regarding factors under consideration for payment determination by an independent dispute resolution (IDR) entity.

The court decided the Department of Health and Human Services (HHS) was mistaken to instruct IDR entities to make the qualifying payment amount (QPA) the primary factor in determining payment for out-of-network services. The QPA is the median of the contracted rates for the same service provided by a provider in the same or similar specialty in the same geographic region. The QPA had received more weight than other factors, such as a provider’s level, training, or experience and a facility’s teaching status, case mix, or scope of services.

In a memorandum, HHS stated it has withdrawn guidance documents that are based on or refer to this section of the rule and will post new guidance documents on the No Surprises Act webpage once they are updated. The agency will provide training on the revised guidance and reopen the IDR process for submissions through the IDR portal.

Contact Senior Director of Policy Erin O’Malley at eomalley@essentialhospitals.org or 202.585.0127 with questions.

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About the Author

Julie Kozminski is a senior policy analyst at America's Essential Hospitals.

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