STAT+: Providers notch No Surprises Act legal win that could boost their pay

Tara covers the business of health care. Her stories focus on hospitals, doctors, and how their business practices affect patients — especially when private equity gets involved. She also writes about health insurance and ideas for improving our broken health system. You can reach Tara on Signal at tarabannow.70.A highly anticipated No Surprises Act court decision delivered yet another win for providers, finding that the government erred in its instructions for calculating the amounts health insurers typically pay for services. Tuesday’s decision from the U.S. Court of Appeals for the Fifth Circuit stems from a 2022 Texas Medical Association lawsuit challenging the government’s rule for calculating the qualifying payment amount, a number that’s used in arbitration to represent health insurers’ contracted rates for services. The trade group for doctors had argued that the methodology yielded numbers that were unfairly low, and the court mostly agreed. The Fifth Circuit sided with providers against the federal government on two of three points: that the QPAs should not include so-called ghost rates, or placeholder rates that providers don’t actually negotiate, and that they should include bonus and incentive payments. It disagreed with air ambulance providers, finding that a one-off price for transporting a single patient should not factor into QPAs. STAT+ Exclusive Story Already have an account? Log in This article is exclusive to STAT+ subscribers Unlock this article — plus in-depth analysis, newsletters, premium events, and news alerts. Already have an account? Log in View All Plans To read the rest of this story subscribe to STAT+. Subscribe