| A federal appeals court dealt insurers another setback in the long-running fight over how much they should pay out-of-network providers under a law meant to protect patients from surprise medical bills. → The case centered around what’s known as the qualifying payment amount, or QPA, and how it should be calculated. The figure is meant to represent the median in-network rate as a key benchmark when insurers and providers haggle over out-of-network payments in the arbitration process. It’s the latest blow to how regulators have set up the QPA, a point of contention between insurers and providers since regulators began implementing the law — called the No Surprises Act — in 2021. The Texas Medical Association and other providers argued that federal regulators had skewed the calculation by allowing insurers to count “ghost rates” — low monetary amounts listed in contracts for services a provider never actually performs — as part of the QPA. The complaint also took issue with regulators allowing insurers to exclude bonus and incentive payments for services from the calculation. → A majority of the 17-judge Fifth U.S. Circuit Court of Appeals agreed, arguing that the rules kept the QPA artificially low. “The agencies’ error has upended the [No Surprises Act’s] dispute-resolution process,” the majority wrote in an unsigned decision. The court did not, however, require insurers to count one-off agreements — including arrangements commonly used by air ambulance providers — in the QPA. Bradford W. Holland, president of the Texas Medical Association, said in a statement that the ruling is “another step in the right direction for both patients and the physicians who care for them.” → The ruling could ultimately push the benchmark rates higher, strengthening providers’ hand in the law’s arbitration process. “For years, insurers have systematically underpaid doctors using QPAs that don’t pass the laugh test. The Fifth Circuit just took away one of their tools to do it,” said Patrick Velliky, chief external affairs officer of HaloMD, a company that helps physicians with the arbitration process. There’s been far more disputes submitted to arbitration than the 17,000 per year that the government had initially predicted. The Centers for Medicare and Medicaid Services reported that roughly 2.6 million billing claims had been submitted last year. However, providers are already victorious in about 85 percent of the most recent billing disputes brought to arbitration, and are winning amounts above the QPA about 87 percent of the time, according to government data. → In the ruling, the court pointed to those outcomes as evidence that the QPA is too low. Other parties, including insurers, have used the same figures to claim that some providers — and companies such as HaloMD — are rigging the system in their favor. “Some out-of-network providers and arbitration middlemen continue to abuse the No Surprises Act — flooding the system with ineligible claims, gaming arbitration for inflated payouts, and attacking the law in court — undermining the intent of Congress and the president and driving up health care costs for everyone,” said Chris Bond, a spokesperson for insurance industry group AHIP, in a statement about the ruling. Some insurers and employer groups have also argued that there is a “structural conflict of interest” for arbitrators because they are paid for each case they decide. That payment model, they said, gives the entities an incentive to process as many cases as possible rather than prioritize impartiality in their decisions. WHAT TO WATCH The court, pushing back on arguments from the federal government and insurers, said that overturning the rules “will not result in all-out chaos.” The majority of judges on the panel wrote that agencies can use enforcement discretion to let insurers keep using existing QPAs while they develop new calculations — so the decision doesn’t immediately leave patients exposed to sky-high bills if they unwittingly see an out-of-network provider. The rules, implemented by the Biden administration, had been defended in court by the Trump administration. But it’s not yet clear if the agencies that drafted them — the Treasury, Labor and Health and Human Services departments — will appeal, or take the loss and go back to the drawing board. “This opens up a new path for additional regulatory changes this year,” said a person who works for insurers, who spoke on the condition of anonymity to discuss the dynamics, though they expect regulators to be cautious when writing new rules so as to avoid additional legal challenges. “In terms of difficulty, the complexity will depend on how CMS structures the changes, but it will be a substantial lift to recalculate all the QPA values,” the person said. HHS, which primarily oversees the surprise billing dispute process, did not respond to questions about whether it wants to appeal the ruling. → All eyes are also on CMS because the agency told the New York Times last month that it is “actively working to clean” up the arbitration system, which it says is “being gamed to get higher prices.” Those plans haven’t yet become clear. Inter-industry fight over the No Surprises Act has driven more intense lobbying this year, spearheaded by insurers who argue that some providers are abusing the arbitration system. However, there are more provider-aligned forces — which have primarily been winning in court — are jumping into the advocacy game. Pivotal Health, which helps doctors file claims under the No Surprises Act, recently hired DLA Piper to lobby on its behalf. “We hit the ground running,” Darren Patz, a partner at the firm who is leading the work, tells me. Pivotal Health’s lobbying team at DLA Piper also includes former North Carolina senator Richard Burr, who previously served as the top Republican on the Senate Health, Education, Labor, and Pensions (HELP) Committee. Patz, who spent nearly 20 years in senior roles at Pediatrix Medical Group, says the team working for Pivotal Health has been meeting on Capitol Hill with committees of jurisdiction and with officials at CMS about “improvements” that can be made to how the surprise billing law is implemented and enforced. “We want to make sure that this is not done with a machete and is done properly with a scalpel,” he said, mentioning that the company is lobbying to increase enforcement over insurers and payments following arbitration, among other issues. The Texas Medical Association decision shows that “this is a process,” Patz said. “I do think that this is a journey that is still just beginning” — even if it is six years after the first rules were released. Eli Lilly has filed six lawsuits against wellness companies accused of illegally selling versions of its experimental weight-loss drug retatrutide, escalating its effort to crack down on a growing online market, The Post’s Christopher Rowland reports. Retatrutide has attracted intense interest because clinical studies suggest it may be more potent than existing GLP-1 weight-loss drugs. That demand has prompted websites and med spas to market purported versions of the drug before approval by regulators. → The drug is still in clinical trials, and Eli Lilly expects to ask the Food and Drug Administration to approve it by the end of the year. If approved, the earliest it could reach the market would be 2027. Eli Lilly said some sellers are exploiting a federal provision that permits experimental compounds to be sold for research purposes, while still marketing them for human use. The company and the FDA have warned that such products can violate federal law and pose health risks. The compounds are often made overseas in facilities that have not been inspected or licensed by U.S. regulators, and their ingredients may not be verified. Read the full story: “Eli Lilly sues vendors accused of hawking versions of its experimental GLP-1.” - Zoom out: Eli Lilly’s retatrutide lawsuits are the latest escalation in a legal campaign that began with complaints involving the company’s blockbuster GLP-1 drugs Mounjaro and Zepbound, which both contain the active ingredient tirzepatide.
- Eli Lilly sued at least 10 med spas and compounders in 2023, followed by more cases against several pharmacies and telehealth companies last year.
Medical technology industry group AdvaMed has named JC Scott as chief strategy office and executive director of AdvaMed Accel. The group says the latter is a newly created leadership position intended to build relationships with newer medical technology companies and make the trade group more influential in the health-tech innovation space. Scott most recently served as CEO of the Pharmaceutical Care Management Association, which represents pharmacy benefit managers, from 2018 to 2025. But the new gig is a homecoming for him, as Scott had previously held senior advocacy roles at AdvaMed from 2011 to 2018. “Trump administration to end Medicaid funding for children’s transgender care,” The Post’s Cat Zakrzewski and Dan Diamond report. “Severe malnutrition in Somalia is surging after U.S. cuts, aid groups say,” The Post’s Rael Ombuor reports. “Scientists say U.S. will suffer if White House bars research with China,” The Post’s Cate Cadell reports. “A Group of Centrist Senators Sees a Window to Overhaul Social Security,” Jeff Stein writes at NOTUS. “ | 
