Fifth Circuit ruling in Texas Medical Association case reshapes No Surprises Act payment benchmark for Nutex

The Fifth Circuit, sitting en banc, vacated key parts of the July 2021 rule underpinning No Surprises Act payment benchmarks.

The ruling bars insurers from using “ghost rates” in Qualifying Payment Amount calculations for out-of-network reimbursement disputes. Insurers must also include bonus and incentive payments in QPAs, reversing an approach the court said artificially deflated benchmarks.

Providers such as Nutex negotiate rates around QPAs, with unresolved cases moving to independent dispute resolution arbitration. The court directed agencies to allow continued use of existing QPAs until new rules reset calculations consistent with the statute.