Description: Dallas, Texas commercial litigation lawyers represented the parties in a dispute over payment for out-of-network healthcare services.

Congress enacted the NSA in 2022 to protect patients from surprise
medical bills incurred when they receive emergency medical services from
out-of-network healthcare providers. See 42 U.S.C. §§ 300gg-111, 300gg-112.
The NSA achieves this by, inter alia, relieving patients from financial liability
for surprise bills and creating an Independent Dispute Resolution (“IDR”)
process for billing disputes between providers and insurers. Id. § 300gg-
111(c)(1)–(5); see generally Tex. Med. Ass’n v. United States Dep’t of Health &
Hum. Servs., 110 F.4th 762, 767–78 (5th Cir. 2024) (discussing the NSA).1
Under the IDR provisions, the provider and insurer first try to agree
on a price for the services. Id. § 300gg-111(c)(1)(A). If the negotiation fails,
the provider or payor has four days to initiate IDR proceedings. Id. § 300gg-
111(c)(1)(B). If the parties pursue IDR, either the parties or the Department
of Health and Human Services (“HHS”) selects a certified independent
dispute resolution entity (“CIDRE”) to referee. Id. § 300gg-111(c)(4).
The CIDRE determines the amount the payor owes the provider. Id.
§ 300gg-111(c)(5). The CIDRE sets that amount via “baseball-style”
dispute resolution where the provider and insurer each submit an offer, and
the CIDRE selects one party’s offer as the award. Id. §§ 300gg-112(b)(5). In
selecting which offer to award, the CIDRE must consider the insurer’s
“qualifying payment amount,” a heavily regulated rate that reflects the
“median of the contracted rates recognized by the plan or issuer . . . for the
same or a similar item or service” offered in the same insurance market and
geographic area. Id. § 300gg-111(a)(3)(E)(i).

In the absence of a fraudulent claim or evidence of a misrepresentation
of facts to the CIDRE, the IDR award “shall be binding upon the parties
involved,” and payment of the award “shall be made . . . not later than 30
days after the date on which such determination is made.” Id. § 300gg-
112(b)(5)(D) (incorporating 42 U.S.C. § 300gg-111(c)(5)(E)); id. § 300gg-
112(b)(6). Patients are not involved in open negotiations or the IDR process,
and payors are directed to issue any IDR award payments directly to the
provider. See id.§ 300gg-112(b)(1)(A), (b)(5)(B), (b)(6).

The NSA also provides that an IDR award “shall not be subject to
judicial review, except in a case described in any of paragraphs (1) through
(4) of section 10(a)” of the Federal Arbitration Act (“FAA”). Id. §§ 300gg-
112(b)(5)(D), 300gg-111(c)(5)(E). HHS has the authority to enforce
provider and payor non-compliance with the NSA’s provisions. Id. § 300gg-
22(b)(2)(A) (providing for HHS enforcement against some payors for NSA
non-compliance); id. § 300gg-134(b) (providing for HHS enforcement
against providers for NSA non-compliance).

Outcome: Motion of dismiss granted.

Affirmed

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