TMA Opposes Congressional Proposal to Cap Office-Based Physician Pay
By Emma Freer

US capitol

The Texas Medical Association’s fight for a fair implementation of the federal surprise-billing law continues on a new front, with recently proposed legislation threatening to expand the use of an opaque and flawed formula that already has sparked several TMA lawsuits.  

The Primary Care and Health Workforce Expansion Act, introduced by Sen. Bernie Sanders (D-Vermont) on July 19, proposes capping reimbursement for certain health care services provided in physician offices at the qualifying payment amount (QPA).  

TMA in a statement voiced its deep concern “with the proposal to convert the [QPA] benchmark into a rigid price ceiling for office-based physician services,” which it warned “would set a dangerous precedent with disastrous unintended consequences for patients” and physicians.  

“[This bill] will add to the immense pressures physicians already face in an environment of high costs and eroding reimbursement across all payers,” the association continued. “Ultimately, patients will pay the price with lower quality and less accessible care.” 

The QPA is a feature of the 2020 federal No Surprises Act, which prohibits balance billing for certain out-of-network care. Under the law, the QPA generally is supposed to be the median in-network rate for the service provided by a physician in the same or similar specialty in the relevant geographic area.  

TMA has sued federal authorities four times over rulemaking for the law, saying they have failed to follow clear direction from Congress on how to implement its dispute resolution process and related processes. Specifically, the association has challenged certain parts of the rules that: 

  • Artificially deflate the QPA, skewing negotiations in favor of health insurers so strongly that health insurers have forced physicians out of insurance networks, exacerbating practice viability and access-to-care challenges; and
  • Give outsized weight or consideration to the QPA during arbitrations, which also unfairly benefits insurers.  

TMA received favorable rulings at the district court level in its first two lawsuits concerning the weighting of the QPA during arbitration, one of which is currently being appealed by the federal government to the Fifth Circuit. TMA also secured a victory in its fourth lawsuit regarding an excessive fee hike. A third lawsuit pending at the district court level challenges certain portions of the interim final rules regarding how the QPA is calculated. 

“Both the Administration’s proposed implementation of the [No Surprises Act] and now this legislative proposal distorts the reality that the [law] intended to preserve market-based negotiations between physicians and insurers,” TMA said in the same statement.  

The U.S. Senate Committee on Health, Education, Labor & Pensions, which Senator Sanders chairs, was originally due to consider the legislation on July 26, but has postponed the hearing to September as bipartisan talks continue.   

For more information, check out TMA’s Surprise Medical Bills webpage.  

Last Updated On

August 07, 2023

Originally Published On

August 07, 2023

Related Content

Insurance | Surprise Billing

Emma Freer


(512) 370-1383

Emma Freer is a reporter for Texas Medicine. She previously worked in local news, covering city politics, economic development, and public health. A native Clevelander, she graduated from Columbia Journalism School and the University of St. Andrews.

More stories by Emma Freer