Wolfe | Pincavage

The Fifth Circuit recently affirmed a lower court’s decision to vacate key portions of regulations under the No Surprises Act (NSA). The ruling is a win for healthcare providers, as the vacated regulations had unfairly prioritized insurer interests in the arbitration process to determine out-of-network payment rates. The court held that these regulations exceeded the Departments’ authority and tilted the scales in favor of insurers by prioritizing the Qualifying Payment Amount (QPA) over other factors mandated by the NSA. This decision underscores the importance of a balanced and equitable approach to resolving payment disputes under the NSA. Read The National Law Review for the full analysis.

Associate Attorney Daniel Rubio penned an article for the WolfePack Wisdom series on our website. He dives into the growing trend of health insurance companies utilizing artificial intelligence (AI) to deny claims. While AI has the potential to streamline processes, concerns are rising about its use in denying legitimate claims and creating unnecessary hurdles for patients and providers. Read Daniel's full post here:

A win for providers! The 5th Circuit Court of Appeals has upheld a lower court's ruling, finding that the federal government's interpretation of the No Surprises Act infringed on the discretion of independent arbiters in determining out-of-network payments. The dispute centered around the "qualifying payment amount" (QPA), a metric set by insurers. The court found that the government's rules unfairly favored insurers by requiring arbiters to prioritize the QPA over other factors. This decision is a significant victory for providers and may lead to changes in the dispute resolution process.

The Centers for Medicare & Medicaid Services (CMS) recently updated its Overall Hospital Quality Star Ratings on its Care Compare website and Provider Data Catalog. Approximately 4,600 hospitals nationwide were assessed on 46 hospital quality measures, and 381 hospitals were assigned five stars. These ratings, released on July 31, 2024, are based on factors such as safety of care, readmission rates, patient experience, timeliness of care, and mortality rates. While the data reveals a slight decline in overall hospital performance compared to last year, it's important to note that this data reflects the ongoing challenges faced by healthcare providers during the COVID-19 pandemic. It is also important to note that fewer hospitals received ratings this year, partly due to challenges in reporting sufficient data. The American Hospital Association and other groups are advocating for CMS to improve the methodology to ensure that hospital performance is portrayed accurately and fairly.

A huge congratulations to Lindsay Burrows on being named one of the Best Lawyers: Ones to Watch® in America for 2025! Your expertise and commitment to excellence inspires us.

Batter up! ⚾️ Last week, we traded our legal briefs for peanuts and cracker jacks at a Marlins game. A big thanks to the Wolfe Pincavage team for making it a memorable day! Miami Marlins and loanDepot park

We are pleased to announce that Raneem Shehadeh has joined the Wolfe Pincavage team as an associate attorney! In her new role, Raneem will be a valuable asset to our healthcare team, providing critical support on various regulatory matters. We're excited to have her on board and can't wait to see the contributions she'll make! Please welcome Raneem 👏

Wolfe Pincavage's latest WolfePack Wisdom blog post delves into the new U.S. Department of Health and Human Services (HHS) rule establishing "Disincentives" for Health Care Providers, which has just gone into effect. The article covers the origins of the rule, its scope and applicability, and the potential implications for healthcare providers. A big thank you to our summer law clerk, Dr. Jordan Brooks, MD, JD, MPH, for this insightful contribution!

Congratulations to Partner Becky Greenfield, JD, MPH on her commitment to Florida Chapter HFMA. Wishing you and the board much success!

The first half of 2024 has witnessed significant activity in healthcare provider M&A, with 31 announced hospital mergers. While the second quarter saw a slight dip compared to the first, the transacted revenue remained near historic highs, highlighting a sustained interest in consolidation within the sector. Despite potential regulatory hurdles, the momentum in healthcare provider M&A is expected to persist. Financial pressures, strategic goals, and the pursuit of innovative care models will continue to fuel this trend. Read more here: