Also called “balance bills,” surprise billing is the phenomenon in which patients receive charges for medical procedures that are the difference between the provider’s price and the amount insurance companies agree to pay.
They often arrive long after the procedure occurs due to how long it can take for the negotiation between the health care provider and the insurance company to be resolved.
Filed on Thursday, TMA’s suit challenges one subset of the federal government’s rule cracking down on surprise billing.
“TMA’s lawsuit challenges one component of the administration’s rule that ignores congressional intent and unfairly gives health plans the upper hand in establishing payment rates when a patient receives care from an out-of-network physician, oftentimes in an emergency,” TMA President Linda Villareal said.
The No Surprises Act was passed by Congress in December 2020 restricts the ability of insurance companies to charge out-of-network rates for certain services. After months of consideration and public comment, the federal government issued its final rule for enforcement of the law. It is set to go into effect on January 1, 2022.
In layman’s terms, TMA alleges the rule takes authority out of arbitrators’ hands, who were designated by Congress to exercise discretion, and ties them to the insurance companies’ “qualifying payment amount” (QPA).
The QPA is a gauge from which to approach cost-sharing enterprises rather than individual patients. This QPA rate may differ from the actual market rate and the plaintiffs worry the rule warps a reference point crucial to the dispute resolution process. If it weighs one consideration at the expense of others, then it could affect the amount patients pay out of pocket.
Specifically, TMA says the rule will “driv[e] down reimbursement rates and encourage[e] insurance companies to continue narrowing their networks.”
They also allege the federal government violated the public notice and comment period protocols of bureaucratic rulemaking.
“We are disappointed the Biden administration ignored congressional intent and essentially set up the arbitration system to operate like a casino, with health insurers playing the role of the house,” Villarreal added. “Everyone knows the house always wins. With the current rule, patients, physicians, and our country lose.”
The suit was filed in the U.S. District Court for the Eastern District of Texas, based in Tyler.
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Brad Johnson is a senior reporter for The Texan and an Ohio native who graduated from the University of Cincinnati in 2017. He is an avid sports fan who most enjoys watching his favorite teams continue their title drought throughout his cognizant lifetime. In his free time, you may find Brad quoting Monty Python productions and trying to calculate the airspeed velocity of an unladen swallow.