August 04, 2023

Radiology and Patient Access to Quality Care Win Again in Surprise Billing Federal Suit

Government Suspends IDR Process in Wake of Court Ruling

The U.S. District Court for the Eastern District of Texas ruled in favor of patient access to quality care and sensible physician reimbursement in an Aug. 3 decision against the federal government’s implementation of the No Surprises Act (NSA). The court ruled in a suit brought by the Texas Medical Association, Texas Radiological Society, Houston Radiology Associated and others (dubbed “TMA IV”) that the government’s “fee increase and batching rule” implementing the NSA violated federal law.

The American College of Radiology® (ACR®), American College of Emergency Physicians (ACEP) and American Society of Anesthesiologists (ASA) filed a joint amicus brief with the Texas court showing how fee guidance published Dec. 23 by the Centers for Medicare and Medicaid Services is infeasible, particularly for radiologists. CMS increased a non-refundable administrative fee to contest disputed insurer reimbursement from $50 to $350, a 600% increase. This drastic increase renders the Independent Dispute Resolution (IDR) process infeasible for many providers — particularly radiologists — whose billed services are less than $350 the vast majority of the time.

ACR, ASA and ACEP issued a joint release Aug. 8, with more detail about the court decision.

This is the third case in which the court has decided that the government’s rules to implement the NSA exceed its legal authority.

In the latest case, the plaintiffs alleged the government failed to provide legally required notice and comment about the drastic administrative fee increase, and deprived the plaintiffs of substantive legal rights.

These plaintiffs also challenged the government imposing significant restrictions on being able to “batch” certain related claims and submit them to an arbitrator.

The court vacated, or nullified, the fee increase and batching rule nationally because the government failed to allow ACR members and others to comment and propose alternative approaches. In accordance with the court ruling, CMS announced on August 11 that the IDR fee would return to $50, the amount originally set through rulemaking in October 2022, for IDR claims initiated on or after August 3, 2023. The agency indicated that the Federal IDR portal would reopen “soon” to allow submission of new disputes.

The federal court in Texas has overseen four lawsuits against the government’s implementation of the NSA. The government will evaluate whether to appeal the court’s decision or revise the parts of the IDR rules that the court vacated.

Notably, the government has suspended the IDR process, effective immediately, because of the TMA IV decision. CMS termed this as an “Unplanned Outage.” ACR members now must await further government guidance on how to submit claims under the IDR process for reimbursement of services.

ACR will continue to provide updates as developments occur. If you have question or would like more information, contact Tom Hoffman, ACR Vice President, Legal.