Healthcare Providers Vs Insurance Companies: Lawsuits Stemming from the No Surprises Act

insurance versus healthcare providers

The No Surprises Act and its IDR process has healthcare providers and insurance companies slinging lawsuits left and right, challenging the NSA and each other. Below, find a collection of news about lawsuits related to the NSA and its biased IDR process, with the most recent entries on top.

Congratulations are in order, again, for Texas Medical Association (TMA) – and their legal victory on February 6th is a big one for patients and physicians. A federal judge ruled in favor of TMA’s challenge to HHS’s No Surprises Act QPA rule.

 

The requirement originally instructed IDR entities to select the out-of-network rate closest to the qualifying payment amount (QPA) for final payment determination.

 

In a statement from TMA president Gary W Floyd, “The decision will promote patients’ access to quality care when they need it most and help guard against health insurer business practices that give patients fewer choices of affordable in-network physicians and threaten the sustainability of physician practices.”

While TMA’s victory has led to the long overdue reconsideration of the IDR process, it also means the process must come to a screeching halt.

CMS has asked IDR entities to halt all payment determinations until HHS and the Treasury Department issue further guidance.

This comes after February 6th’s federal court ruling in favor of TMA, confirming that the NSA revised arbitration process “continues to place a thumb on the scale” in favor of insurers and “that the challenged portions of the final rule are unlawful and must be set aside.”

While the victory is important and may lead to a more impartial IDR process, the backlog of claims will continue to grow and physicians must wait longer for payment.

It’s lawsuit number four for the Texas Medical Association (TMA), as they challenge the 600% hike in administrative fees to access the No Surprises Act’s IDR process. TMA argues that when health plans offer insufficient payments for care, this steep increase in fees will severely curtail physician arbitration rights.

This lawsuit against federal agencies challenges a steep administrative fee increase that will strip many physician and healthcare providers of the arbitration process that Congress enacted.

According to the organization, the administrative fee hike is difficult for all physician specialties, especially those with more small-dollar claims – such as radiology.

In a statement, TMA argues that the fees are “arbitrary,” “capricious,” and contrary to law.

On December 19th, the Texas Medical Association (TMA) presented its case challenging the implementation of the No Surprises Act in District Court.

The TMA hoped the payment dispute resolution process will be tossed out because it “unfairly benefits insurers,” while regulators disagree with this claim.

If the TMA succeeds, the IDR process could potentially be halted for re-evaluation.

For an alternative means of recovering provider revenue tied up in the IDR process, contact Allia Group. 

We would like to congratulate TeamHealth on their victory in their lawsuit.

In early December, UnitedHealthcare was ordered to pay TeamHealth $10.8 million to settle underpayments from 2017 – 2020.

There is plenty of work to be done to recover underpayments for many emergency physician groups.

On September 22, 2022, the Texas Medical Association (TMA), Dr. Adam Corley and Tyler Regional Hospital sued the Biden administration again over the implementation of the IDR process under the NSA.

According to the article, under the rebuttable presumption, IDR entities are directed to select the offer closest to the QPA unless parties submit credible information about additional circumstances that clearly demonstrate a QPA materially different than the appropriate out-of-network rate.

Providers find this presumption improper without opportunity for advance public notice and comment, in violation of the Administrative Procedure Act, and even the Fifth Amendment.   

Higher premiums and healthcare costs should not and cannot be the outcome.

In September 2022, National physician staffing firm Envision Healthcare announced it is suing UnitedHealthcare for denying payment of emergent care claims and not paying providers for out-of-network emergency services. Last year, UnitedHealthcare cut 25,000 clinicians from Envision’s network. 

This is problematic.

When a patient needs an emergency procedure, providers should not be punished just because they were not in a specific health insurance network. 

Envision ultimately pursued litigation to receive underpayments. It’s an especially important tactic since the alternative IDR system is unreliable and skewed in the insurance company’s favor.

 

The American Medical Association (AMA) and American Hospital Association (AHA) have withdrawn a lawsuit against the federal government’s implementation of the No Surprises Act as of September 20, 2022.

These groups originally filed suit over interim rules which addressed issues about Congress’ rule-making process “placing a heavy thumb on the scale” in favor of insurers during the IDR process.

They hinted at more action in the future, suggesting that both hospitals and doctors intend to make their voices heard in court very soon regarding the No Surprises Act, even after its final ruling.

In July 2022, UnitedHealth was sued over low reimbursement rates for physicians. We continue to see more evidence of aggressive insurance companies reducing in-network rates and pushing providers out of network throughout the country. There is incessant evidence of large insurers aiming to cut costs for themselves by victimizing physicians groups and reducing rates for providing essential care.

With little to no reimbursement, physicians and health plans are left without reasonable compensation for their work.

This is just one of the reasons Allia Group fights so passionately for healthcare providers—we serve as a resource for physicians groups to receive reimbursements they deserve.

Litigation works. In fact, according to the Indianapolis Business Journal, local physicians are set to recover $4.5 million from Anthem as of April 18, 2022. Anthem’s triage fees were deemed illegal and their downgraded claims negatively impacted 60-70% out of thousands of ER claims.

The affected hospitals say they could claim another $12 million in additional damages, as disputed claims increase.

Allia Group works to produce similar results. We recover and finance underpaid out-of-network claims, bridging the gap between reasonable billed rates and the amounts insurers pay.

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