5th Circuit strikes down No Surprises billing benchmark in win for providers

Healthcare Dive – Thursday, August 13, 2026
By Rebecca Pifer Parduhn

Dive Brief:

• A federal appeals court has struck down the methodology used to determine how much providers should be reimbursed in disputes over out-of-network bills under the No Surprises Act. It’s a blow for insurers, given the ruling is set to further inflate payouts to providers.
• On Tuesday, the 5th Circuit ruled that the government’s methodology for calculating the qualifying payment amount — a metric representing average in-network rates for a service in a particular geographic area — is partly unlawful. The majority of judges agreed with the Texas Medical Association and other plaintiffs on two of their three challenges to the rule, stating that the government violated the law by letting insurers include “ghost rates” in QPA calculations and by excluding bonus and incentive payments.
• However, agencies were correct in excluding one-off agreements, like those common in air ambulance billing, the 5th Circuit said. Though the court vacated the QPA methodology, it said that agencies can allow insurers to use existing QPAs until they can calculate new ones so that the NSA’s dispute resolution process can continue without interruption.

Click here to read the entire article.