Once again, a federal judge in Texas agreed with physicians that the government’s regulations for the No Surprises Act are inconsistent with the statute. In a lawsuit filed by the Texas Medical Association (TMA), a federal district court judge on February 6 removed regulatory provisions regarding the independent dispute resolution (IDR) process and granted the association’s motion for summary judgment.

The judge had agreed with the TMA that the government’s latest regulations still heavily weighed on the qualifying payment amount (QPA) in the payment determination, which favors insurers and “places a thumb on the scale.” The decision was a victory for physicians, including pathologists, who have fought against the improper regulations.

CMS Pauses IDR Decisions

Following the decision, the Centers for Medicare & Medicaid Services (CMS) said it was in the process of evaluating and updating the federal IDR process. “Effective immediately, certified IDR entities should not issue new payment determinations until receiving further guidance from the Departments,” the CMS said on February 10. “Certified IDR entities also should recall any payment determinations issued after February 6.”

The 2020 No Surprises Act protects patients from unexpected medical bills and limits how much they can be charged for emergency and non-emergency services from out-of-network providers. It also established an arbitration (IDR) process for when payers and providers disagreed about those rates.

An interim final rule for the IDR process originally disregarded Congress’ intentions of creating a fair system where physicians and health insurers can resolve disputes without one payment determination factor having more weight than another. However, under the revised final rule, the CMS continued to direct arbitrators in the IDR process to disregard certain factors, just as the interim final rule did.

The CAP and many other provider groups had warned that these kinds of requirements for the IDR process heavily favor insurers and would cause substantial harm to physicians.