In this week’s Zotec Answers podcast episode, Ed Gaines, Vice President of Regulatory Affairs and Industry Liaison for Zotec Partners, explores the latest updates regarding the No Surprises Act (NSA), including developments in the recent litigation from the Texas Medical Association (TMA) and guidance issued by Centers for Medicare and Medicaid Services (CMS) and the Center for Consumer Information and Insurance Oversight (CCIIO).  

The TMA III case highlights long-standing concerns about how health plans calculate the Qualifying Payment Amount (QPA), a critical factor in determining both patient cost-sharing and provider reimbursement. The litigation has drawn attention to the use of “ghost rates” that artificially lower QPA values, disadvantaging physicians. TMA is petitioning to have a rehearing, seeking stronger protections against these practices, following a mixed appellate court ruling.  

In response to these challenges, CMS and CCIIO recently issued FAQs addressing two pressing issues. First, the agencies reminded health plans that “re-adjudicating” claims after losing an IDR determination – by illegally increasing patient cost-sharing – is a violation of the law. Second, the guidance reinforced that health plans must fulfill IDR payment obligations within 30 days, a legal requirement that plans have frequently failed to meet.  

To learn more, tune in to the latest episode of Zotec Answers. Stay informed about future NSA updates and other critical healthcare topics by subscribing to Zotec Answers today. 

For more information on the TMA III case, listen to this earlier episode of Zotec Answers and checkout this A to ZPAC blog post.