STAT+: Providers notch No Surprises Act legal win that could boost their pay
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- The Fifth Circuit ruled in favor of providers on two of three points in the No Surprises Act case, finding the government erred in its instructions for calculating qualifying payment amounts (QPAs) used in arbitration.
- Texas Medical Association, the doctors' trade group that filed the 2022 lawsuit, argued the QPA methodology yielded unfairly low numbers, and the court mostly agreed.
- The court agreed QPAs should not include so-called "ghost rates" — placeholder rates providers don't actually negotiate — and that they should include bonus and incentive payments.
- The court sided with air ambulance providers' argument in part but ultimately found that a one-off price for transporting a single patient should not factor into QPAs.
- QPAs represent health insurers' contracted rates for services and serve as the baseline figure in payment disputes, meaning the ruling's methodology changes could shift future arbitration outcomes in providers' favor.
Why it matters: Because QPAs are the benchmark used in arbitration to determine how much insurers reimburse providers for out-of-network care, the court's directive to exclude ghost rates and include bonus payments could push those arbitration amounts higher — a direct financial lift for providers and hospitals that frequently use the dispute process.
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