The CMS has instructed arbiters to resume all recent payment dispute determinations relating to the No Surprises Act after the agency was forced to pause determinations following a February federal court ruling.
The agency had previously paused and resumed earlier disputes between payers and providers after a Texas judge ruled a second time against the federal government, saying that the dispute process for the No Surprises Act was unlawful and unfairly favored insurers.
On Friday, the agency said that payment determinations could resume for disputes furnished on or after Oct. 25, 2022. It also announced that the majority of disputes will now appear from an automated agency email address.
The No Surprises Act was enacted in January 2022 in an attempt to protect patients from receiving surprise medical bills, but the payment dispute process set up between payers and providers has faced several lawsuits from provider groups, including the Texas Medical Association, arguing that the process unfairly benefits insurers.
Lawsuits have centered around the guidance directing arbiters to anchor decisions to the median in-network rate for healthcare services, or the qualified payment amount, which is set by insurers.
Texas Judge Jeremy Kernodle had previously ruled to nix the language in the No Surprises Act that instructed arbiters to begin with the qualified payment amount, but ruled again in February that the process still privileged the payment amount, “tilting arbitrations in favor of insurers, and thereby lowering payments to providers.”
Lawsuits have forced the CMS to halt and restart arbitration as it works to incorporate court rulings into its dispute guidance.
Even though the No Surprises Act went into law last year, one in five Americans surveyed in June still reported receiving surprise medical bills.
