Bradley partner Stephanie Hoffmann was quoted in a Part B News article discussing a Texas court’s block of the baseline fee determination in the No Surprises Act.
The court vacated one feature of the independent dispute resolution (IDR) process outlined in the federal government’s No Surprise Act regulations, a decision that may result in more providers challenging prices named by the government — and cause them to go up.
Before this ruling, the arbitrator performing the IDR had to consider the qualifying payment amount (QPA), the “rebuttable presumption” of a fair payment amount; the further a complainant’s alternative was from the QPA, the less likely it was to prevail.
Hoffmann said “the rule basically put the burden on the providers to explain to the arbitrator why the QPA was not appropriate.” She added, “And only then did they have the privilege of presenting their evidence.”
Providers who perform big-ticket procedures, such as orthopedic surgeons, are most likely to go for it, Hoffman said. “For providers who are, for example, very specialized and may see a huge difference between what they would normally be paid by the insurer under the system and what they think is appropriate, it could be worth it,” she stated. “Once providers start seeing the result other providers get from IDR, there could be an increase.”
The original article, “Court blocks baseline fee determination in No Surprises regs,” appeared in Part B News on March 3, 2022. (login required)