PAMED and AMA Argue for Court Enforcement of No Suprises Awards

Today PAMED joined the AMA and the Medical Societies of Delaware and New Jersey in filing an amici brief concerning enforcement of No Suprises Act arbitration awards. The brief was filed in the Third Circuit U.S. Court of Appeals and argues that federal district court decisions in two cases should be reversed.

In the consolidated cases, Specialty Care, Inc., et al. v. Cigna Healthcare, Inc., and Specialty Care, Inc., et al. v. UMR, Inc., lead plaintiff Specialty Care, a neuromonitoring medical practice, filed suit to enforce more than $1 million in awards owed from health plans, specifically Cigna Healthcare and UMR, Inc., a third-party administrator subsidiary of United Healthcare. Specialty Care was granted the awards after going through the independent dispute resolution (IDR) process provided by the federal No Suprises Act (NSA).

The No Suprises Act was enacted to end the practice of “balance billing” of patients when a health plan declined to pay out the full amount submitted by an out-of-network physician for treatment.  The NSA created a binding and final process whereby, following 30 days of negotiations, if the health plan and physician cannot agree on the payment amount, the matter goes to an arbitrator. Both parties submitted an amount, and the arbitrator chooses one of the amounts to award. This is similar to how such matters are handled in Major League Baseball player contract disputes. The health plan then has 30 days to make payment.

Specialty Care sued because the health plans failed to pay the awarded amounts. Unfortunately, the NSA contains no explicit process to enforce the award. Specialty Care went to court seeking enforcement.

The federal district court dismissed the cases, finding the lack of an explicit enforcement provision in the statute to be determinative. Specialty Care appealed the decisions to the Court of Appeals.

The brief argues that the failure to enforce IDR awards would harm physicians, particularly independent physicians, who treat out-of-network by destroying the statutory process intended to resolve billing disputes. The brief also argues that statutory interpretation and the NSA’s legislative history demonstrate that Congress did intend for IDR awards to be enforceable in court despite the lack of explicit language. If successful, the court would reverse the district court dismissals and send the cases back to the district court for the cases to be litigated.

Because of the current posture of the cases, permission of the court had to be sought to file the amici brief. That motion was filed. It is anticipated based on past practice that the court will rule to accept the brief. Dates for oral arguments and other procedural benchmarks are still to be determined.