Texas Medical Association Challenges Provisions to IDR Process

Why is this important?

This new lawsuit argues that the QPA is being treated differently, and more favorably, than the additional required information. Specifically, TMA argues that guidance in the Final Rule requires IDR entities to: (a) evaluate QPA first, and additional information second; (b) accept QPA as credible, but weigh the credibility of additional information; (c) accept that the QPA relates to the offer as required by the NSA, but evaluate whether any additional information appropriately relates to the offer; and (d) evaluate whether any additional information may already be incorporated into the QPA and avoid double counting that information if it is.  TMA argues that these additional requirements are not required by the NSA itself; therefore, TMA is asking the court to strike that guidance. 

In support of its position, TMA described the QPA as a “figure calculated in secret by the insurers” that neither providers nor the IDR entities can evaluate or challenge. When Claritev calculates QPA, we always make an explanation of our methodology available to demonstrate transparency in how we comply, and we will now more proactively include that explanation with our IDR briefs.

The first TMA lawsuit moved relatively quickly. The case was filed on October 28, 2021 and the court issued its summary judgement ruling on February 23, 2022. We will continue to monitor this case and provide updates when they are received.   

February 10, 2023: An update is available here.

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