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US appeals court voids medical bill protection formula
The 5th U.S. Circuit Court of Appeals has struck down a key component of the No Surprises Act, specifically the formula used to calculate the qualifying payment amount (QPA). This formula was designed to protect patients from high out-of-network medical bills by establishing a median reimbursement rate.
The court sided with healthcare providers, including the Texas Medical Association, ruling that the QPA calculation was improper because it included “ghost rates”—contracted rates for services never actually provided—and excluded bonus and incentive payments. These changes are expected to result in higher reimbursement rates for providers during arbitration.
However, the court also sided with the government and insurers by allowing them to continue excluding one-off agreements, such as those for air ambulance services, from the contracted rates used in the QPA calculation. To prevent immediate disruption, the court noted that the government may allow insurers to continue using the existing formula while federal agencies craft a replacement.
Entities
5th U.S. Circuit Court of Appeals · Centers for Medicare and Medicaid Services · No Surprises Act · Texas Medical Association · U.S. Centers for Medicare and Medicaid Services
Claims
What the coverage asserts, and how well corroborated each claim is across sources.
- [● 7 SOURCES] The court ruled that the QPA calculation improperly included “ghost rates” and excluded bonus and incentive payments. wdez.com · jack1065.com · kelo.com · wixx.com · ca.news.yahoo.com · +2 more
- [● 7 SOURCES] The 5th U.S. Circuit Court of Appeals struck down a formula used to calculate the qualifying payment amount (QPA) under the No Surprises Act. wdez.com · jack1065.com · kelo.com · wixx.com · ca.news.yahoo.com · +2 more
- [● 7 SOURCES] The court allowed insurers to continue excluding one-off agreements, such as air ambulance services, from the rates used to calculate the QPA. wdez.com · jack1065.com · kelo.com · wixx.com · ca.news.yahoo.com · +2 more
- [● 7 SOURCES] The ruling will not cause immediate chaos as the government can maintain the existing formula while a replacement is developed. wdez.com · jack1065.com · kelo.com · wixx.com · ca.news.yahoo.com · +2 more