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Billing Shocker, Record Data Breach & Telehealth’s New Era
From a major shift in billing 💵 dispute rulings to the largest healthcare data breach in U.S. history, this month brings essential updates for healthcare leaders. Plus, discover how telehealth policies are evolving for 2025 and why Penn State’s $1.25M settlement serves as a crucial warning on cybersecurity 🛡️💻 compliance in federal contracts.
Fifth Circuit's Surprise 😮 Billing Ruling: A Legal Tug-of-War
The Fifth Circuit Court upheld the Biden administration's method for calculating health-provider rates in surprise medical billing disputes, reversing a lower court's decision and addressing challenges related to the No Surprises Act's arbitration process, including the calculation of the median in-network rate and the definition of a "clean claim."
Key Points
The Fifth Circuit reversed a lower court's ruling, supporting the Biden administration's method for calculating the QPA under the No Surprises Act.
The court ruled the inclusion of 'ghost 👻 rates' in the QPA calculation is permissible, countering the Texas Medical Association's argument.
The court found the administration's definition of a 'clean claim' violated the statute, impacting the arbitration process's start date.
The court upheld the agencies' insurance plan disclosure requirements, dismissing the argument that the lack of additional requirements hinder the arbitration process.
What is a “ghost rate”?
A ghost rate refers to a contracted rate between an insurer and a provider that is agreed upon but rarely or never actually paid because no services are rendered under that contract. These rates can still be included in the calculation of the QPA, potentially lowering the median in-network rate used in surprise billing disputes.
Why It Matters
The Fifth Circuit's decision to uphold the Biden administration's calculation method for health-provider rates in surprise billing disputes is a pivotal moment for healthcare arbitration, potentially stabilizing a contentious process that has seen numerous legal challenges. This ruling not only reinforces the current framework but also sets a precedent that could influence future disputes and regulatory adjustments, directly impacting how healthcare providers and insurers negotiate and resolve billing conflicts. For industry leaders, this decision underscores the importance of understanding and adapting to evolving legal standards that govern financial transactions and compliance within the healthcare sector.
Takeaway
Healthcare leaders should closely examine their current billing and arbitration strategies to ensure compliance with the upheld calculation methods, as this decision may influence future regulatory changes and dispute resolutions.