A federal appeals court on Tuesday mostly sided with physicians and air ambulance companies in a challenge to how insurers calculate a key rate under a law designed to protect patients from surprise medical bills.
In an unsigned opinion from the full 17-judge 5th U.S. Circuit Court of Appeals, a majority held that federal agencies improperly allowed insurers to include “ghost rates,” or contracted amounts for services providers never actually deliver, when setting the qualifying payment amount, or QPA. The court also ruled that insurers must consider bonus and incentive payments, rather than exclude them.
The decision leaves intact the agencies’ exclusion of one-off, case-specific agreements, such as those often used in air ambulance services, from the QPA calculation….