The 5th Circuit Court has ruled in favor of the Texas Medical Association, siding with ACEP advocacy and dealing a firm blow to insurance companies.
What they said: The court determined that the insurer calculation known as the Qualified Payment Amount (QPA) cannot include “ghost rates,” which artificially lower reimbursement rates.
Why it matters: The ruling affirms what ACEP has been telling Congress and regulators for years—the QPA is unreliable, fundamentally flawed, and used by insurers to game the system, drive down payments and narrow physician networks.
ACEP filed an amicus brief with the American Society of Anesthesiologists and American College of Radiologists asserting that ghost rates should be excluded from QPA calculations, and that incentive rates and bonus rates should be included.
The court agreed with ACEP on ghost rates and bonus rates, and references ACEP-supported research in its decision that QPAs are artificially low. The decision also emphasizes that the independent dispute resolution case volume is warranted.
Health plans keep losing court battles. Last month, a district judge in Georgia threw out a case brought by Elevance, reinforcing ACEP efforts to spotlight patterns of bad insurer payment policies.
What’s next? The call for prompt passage of the No Surprises Enforcement Act is getting louder. Every ACEP member can speak out:
- Tell Congress to hold insurers accountable via the ACEP Advocacy Action Center.
- Set a meeting with your federal legislators at home with the August Recess Advocacy toolkit (members only).
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