California Medical Association Applauds Federal Court’s No Surprises Act Ruling That Will Protect Patient Access to Physicians

February 24, 2022

The US District Court for East Texas on Wednesday ruled in favor of a lawsuit brought by the Texas Medical Association (TMA) challenging the approach of the US Department of Health and Human Services (HHS ) in dispute resolution under the No Surprises Act (NSA). A Texas judge’s ruling applies nationwide and means that, unless a higher court intervenes, the balanced dispute resolution process that Congress created by the NSA is restored.

Late last year, the California Medical Association (CMA), through the Physicians Advocacy Institute (PAI), filed an amicus brief arguing that HHS’s NSA regulations were contrary to enacted law. by Congress and that by blatantly favoring the insurance industry, patients’ access to network physicians would be harmed in an emergency.

“This is a major victory for patients in California,” said CMA President Robert E. Wailes, MD “The CMA has worked closely with Congress for more than two years to craft legislation that protects patients from surprise medical bills and allows physicians to fairly resolve disputes with insurers, and this decision restores the intent of Congress when it passed this law.

To resolve billing disputes, the NSA’s statutory language called for a process that considers several different criteria; however, flawed HHS regulation strongly favored the median in-network payment rate as the appropriate payment rate to pay for out-of-network services in the dispute resolution process.

The Texas judge agreed that the challenged portion of the settlement was procedurally and substantively flawed because it “conflicts with the unambiguous terms of the statute.” He ordered HHS to immediately rescind the rebuttable presumption standard favoring the median payment rate in the network.

When HHS unveiled the rule, congressional leaders challenged it as inconsistent with their intent and the law’s clear direction. The CMA was concerned that if the dispute resolution process was not balanced, it would discourage insurers from entering into contracts with physicians, significantly reduce fair payments, threaten the sustainability of physician practices, and therefore reduce the patient access to networked medical care.

“The judge clearly agreed with the physician organizations that the median rate of payment in the network was meant to be a dispute resolution factor, not the only factor,” said CMA CEO and PAI President, Dustin Corcoran. “The CMA applauds the court’s decision to follow clear guidance from Congress giving physicians a fair chance to resolve disputes and encouraging insurers to contract with adequate networks of physicians to meet the medical needs of patients.”

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