February 02, 2023

Major Medical Societies Back Texas Medical Association Challenge to Flawed Qualifying Payment Amount

The American College of Emergency Physicians (ACEP), American College of Radiology® (ACR®) and American Society of Anesthesiologists (ASA) support a new Texas Medical Association (TMA) suit filed Jan. 17, stating that key aspects of the federal government’s Surprise Billing interim final rule (IFR) are badly flawed, imposing serious financial pressures on all physicians and resulting in small, independent physician groups, in particular, needing to consolidate or close their practices; thereby causing patients to lose access to care, particularly in underserved areas. ACEP, ACR and ASA filed a joint amicus brief with the Texas court in support of TMA on Jan. 31.

In their joint amicus brief, the medical societies contend that the July 2021 IFR’s methodology for calculating the Qualified Payment Amount (QPA) artificially deflates the QPA by: (1) establishing each contracted rate as a single data point; (2) excluding incentive-based and retrospective payments; (3) including rates for physicians in different specialties; and (4) allowing third-party administrators to determine the QPA based on contracted rates recognized by all self-insured group health plans administered by the third-party administrator. This distorted calculation results in a QPA amount that is not reflective of the fair market value of items and services furnished by out-of-network physicians in the marketplace.

The faulty method for calculating the QPA undermines the ability of physician groups and facilities to obtain adequate payment for out-of-network items and services, artificially deflating the insurer-calculated payment. Further, the inaccurately calculated QPA compounds the defects of the biased IDR process under the August final rule, which favors the QPA and empowers insurers to significantly reduce their in-network rates or terminate in-network agreements altogether.

The brief also notes that the IFR hinders physicians and facilities from engaging in fair contracting negotiations with insurers, which could result in more physicians and facilities being forced out-of-network, threatens their ability to operate, and may result in patients losing access to in-network care.

The Texas case does not in any way impact or undermine the important patient protections included in the No Surprises Act, which ACEP, ACR and ASA advocated strongly for and continue to fully support, nor does it raise patient out-of-pocket costs.