Originally published by our colleagues at Tennessee Medical Association.
Physicians received some very good news this week.
On Aug. 11, the full U.S. Court of Appeals for the Fifth Circuit delivered a significant victory in organized medicine’s long-running fight over implementation of the federal No Surprises Act (NSA).
The court ruled that health insurers cannot use “ghost rates” (contracted rates for services a physician does not actually provide) when calculating the Qualifying Payment Amount (QPA). The court also ruled that insurers cannot exclude bonus, incentive, risk-sharing and other retrospective payments in calculating the QPA.
Why should physicians care about something as technical as the QPA? Because it affects real physician payments.
The QPA is calculated by insurers and plays an important role in resolving out-of-network payment disputes. Organized medicine has argued for years that federal rules allowed insurers to artificially depress the QPA, giving them an unfair advantage in negotiations and forcing physicians to turn to the Independent Dispute Resolution process simply to seek reasonable payment for care already provided.
“The Court’s decision takes the health insurance industry’s finger off the scale and leads to higher out-of-network payment for physicians who win in IDR,” said Yarnell Beatty, TMA’s Senior Vice-President and General Counsel, who has followed the lawsuits closely.
Physicians challenged those rules, and once again, physicians won.
This did not happen overnight. Since 2021, the Texas Medical Association has filed four lawsuits challenging federal regulations implementing the No Surprises Act. Courts have repeatedly agreed that regulators went beyond what Congress authorized, including rejecting rules that gave the insurer-calculated QPA greater weight than Congress intended.
Tennessee physicians have been part of that fight.
The Tennessee Medical Association (TMA) contributed financially to support this litigation, and through the Physician Advocacy Institute (PAI), participated in an amicus brief supporting the first lawsuit. TMA is a founding member of PAI.
“Two administrations have been complicit in implementing federal regulations that favored big insurance in IDR proceedings and ignored Congress’ intent in enacting NSA. TMA recognized from early IDR reports that Tennessee physicians consistently engaged in the process, so we jumped in to help the cause,” Beatty added.
This Is What Organized Medicine Does
Most physicians do not have the time or resources to challenge a federal regulation, follow a case through years of litigation, engage national policymakers, or take on some of the largest insurance companies in America.
That is the value of organized medicine that isn’t always visible in the day-to-day practice of medicine. TMA membership helps give Tennessee physicians a collective voice; in the legislature, before regulators, with insurers and when necessary, in the courts.
There is still work to do. Federal agencies are reviewing the decision; further appeal remains possible, and additional guidance may follow. This week’s ruling is a significant victory and a reminder that persistent physician advocacy can make a difference.
