U.S. District Court finds in favor of TMA regarding the NSA QPA presumption

AAMS Member Alert - February 7, 2023
 
Yesterday the United States District Court for the Eastern District of Texas Tyler Division ruled in favor of plaintiffs Texas Medical Association (TMA) and LifeNet, vacating federal government regulations requiring Independent Dispute Resolution Entities (IDRE’s) to consider the Qualifying Payment Amount (QPA) first in the IDR process, and only to consider other factors in so much as they believe those factors are not already represented in the QPA.
 
The full text of the court’s opinion can be found here.

This decision can best be summarized by the following excerpt (page 23):

…the Act nowhere states that the QPA is the primary or most important factor—or that it must be weighed more heavily than, or considered before, other factors…. Nor does the Act limit arbitrators’ discretion in considering the statutory factors, impose heightened scrutiny on information related to the non-QPA factors, or create procedural hurdles before considering that information. Rather, the Act instructs arbitrators to select one of the two offers submitted by the parties after “taking into account the considerations specified in subparagraph (C).” 

The Departments of Health and Human Services, Treasury, and Labor (the Departments) have yet to respond or issue any further guidance to the IDRE’s. AAMS will share any official response or instruction to the IDRE’s as soon as that becomes available. Without that guidance it is impossible to determine what the direct impact on current and future IDR processes may be, although in previous court decisions the Centers for Medicare and Medicaid Services (CMS) issued guidance quickly informing the IDRE’s of the change. 
 
This decision is a very positive step in ensuring that the IDR process is as fair and transparent as the Congress envisioned, and will hopefully have a positive impact in provider’s standing in the IDR. Additional cases before the courts, including the 3rd case before the East Texas Court from TMA and LifeNet as well as the AAMS case before the District of Columbia court, both dealing with the QPA calculation and other portions of the Interim Final Rule I, remain under consideration by their respective judges.