• TMA I was filed in October 2021; it argued that the interim final rule gave too much weight to the QPA and that nothing in the law stated that arbiters should give added weight to any one factor in their final payment decision. A federal judge ruled in favor of TMA on Feb. 23, 2023, and the tri-agencies agreed to address this language in their final rule.
• TMA II was filed in September 2022 in response to the final rule, which again gave disproportionate weight to the QPA by asking arbiters to consider the QPA first and provide a written explanation of any other factors considered outside the QPA. On Feb. 6, 2023, a federal judge again ruled in favor of TMA. It ordered all IDR entities to pause their rulings through mid-March 2023, when new guidance was finally published.
• TMA III, filed in November 2022, argued that certain aspects of the QPA calculation allowed insurance companies to artificially deflate its value (e.g., the inclusion of ghost rates or unrelated specialties and services, among other issues). On Aug. 24, 2023, a federal judge ruled in favor of TMA, and the federal IDR process was again temporarily paused. The IDR portal has since re-opened, and HHS has filed an appeal in this case.
• TMA IV was filed in January 2023 in response to a sharp increase in IDR administrative fees. Physicians argued that the increase from $50 to $350 would make it cost-prohibitive for some groups to access IDR, especially since batching requirements prevent the efficient bundling of claims (e.g., in emergency medicine, separating claims by type, payer, and service can lead to a high volume of small-dollar batches). On Aug. 3, 2023, a federal judge ruled in favor of TMA and vacated the fee increase as well as part of the batching requirements (that services and items be described by the same service code). However, this decision found only that the rules were passed without following proper procedure. And on Dec. 18, 2023, the tri-agencies issued their revised rules for IDR fees with the proper 30-day notice-and-comment period (as required by statute). The revised fees include an Administrative Fee of $115; and an IDR Entity Fee ranging from $200-$850 for single determinations and $268-$1,173 for batched determinations (up to 25). These new rules went into effect on Jan. 22, 2024.
• Another related lawsuit is the Daniel Haller case, in which a physician argued that the NSA violates certain constitutional rights. However, EDPMA filed an amicus brief that supported neither party in this case, instead expressing concern about how this misinterpretation could affect the viability of existing common-law claims and the scope of IDR. The initial ruling favored HHS, but an appeal is currently underway.

These lawsuits have been an important tool in helping physicians balance the playing field, but they have unfortunately also added to the delays and confusion that have plagued the NSA.