STAT+: Providers notch No Surprises Act legal win that could boost their pay

The U.S. Court of Appeals for the Fifth Circuit recently ruled in favor of healthcare providers, upholding their stance that the government had made an error in its calculations for determining the amounts insurers pay for services. This decision, which stems from a 2022 lawsuit brought by the Texas Medical Association, is a significant victory for providers under the No Surprises Act.

The Texas Medical Association argued that the government's methodology for calculating qualifying payment amounts (QPAs) resulted in numbers that were unfairly low. QPAs are used in arbitration to represent health insurers' contracted rates for services. The Fifth Circuit mostly agreed with the providers on two key points: that QPAs should not include placeholder rates, or "ghost rates," that providers don't actually negotiate, and that they should include bonus and incentive payments.

However, the court disagreed with providers on one point: that a one-off price for transporting a single patient, such as an air ambulance service, should factor into QPAs. The Fifth Circuit held that such a price should not be included in the calculation.