Legal
Fifth Circuit Invalidates No Surprises Act Benchmark Calculation Methods
The Fifth Circuit Court of Appeals ruled Tuesday that insurers cannot include ghost rates or exclude bonus payments when calculating the qualifying payment amount (QPA) under the No Surprises Act. The QPA serves as the default benchmark in independent dispute resolution for out-of-network emergency and air ambulance claims. The decision takes effect immediately and will increase reimbursement amounts paid to out-of-network providers. For Medicaid managed care plans that also operate commercial business, this ruling affects how their commercial lines calculate out-of-network payments, though the No Surprises Act does not apply directly to Medicaid.
Why it mattersThis ruling will increase costs for commercial insurers, including Medicaid MCOs with dual lines of business, and may influence future out-of-network payment disputes in states with similar balance billing protections.