The No Surprises Act (NSA), enacted in 2020, was designed to protect patients from surprise medical bills and to create an independent dispute resolution (IDR) process to fairly resolve out-of-network billing disputes between health plans and physicians. Central to that process is the QPA—a benchmark amount calculated by insurers and used during IDR proceedings.

In 2023, the U.S. District Court for the Eastern District of Texas issued a decision in Texas Medical Association v. U.S. Department of Health and Human Services (TMA III)—the third in a series of lawsuits brought by the Texas Medical Association challenging how federal regulators implemented the NSA. That ruling struck down portions of the QPA calculation methodology, leaving insurers and physicians uncertain which rules applied. In response, federal agencies issued revised regulations later in 2023, but also announced they would exercise enforcement discretion, permitting insurers to continue using the 2021 methodology despite the updated rules.

Most recently, in May 2025, the Fifth Circuit Court of Appeals granted en banc review of the TMA III decision, meaning the full court will reconsider the ruling. That development creates further uncertainty around the status of both the original 2021 rules and the 2023 revisions that were issued in response to TMA III. To avoid disruption in the meantime, regulators extended enforcement discretion, effectively signaling that insurers may continue relying on the 2021 methodology until at least February 1, 2026—and possibly August 1, 2026. In practice, most QPAs being issued today continue to reflect the 2021 rules.

CMA’s Longstanding Concerns with the Regulations

Since the first lawsuit was filed after the initial regulations were published in 2021, the California Medical Association (CMA) has stood with TMA and other national specialty societies in challenging flawed federal rules. From the outset, CMA’s concern has been that the regulations give insurers an unfair advantage in the IDR process by over-weighting median in-network rates and distorting the QPA calculation in ways that do not reflect actual market dynamics. These rules threaten to drive down physician reimbursement, encourage narrower insurer networks, and ultimately jeopardize patient access to care—particularly in rural and underserved communities.

While the latest extension of enforcement discretion provides short-term stability, it does not resolve these underlying problems. CMA will continue to advocate for a fair and balanced implementation of the No Surprises Act that protects patients from surprise medical bills while ensuring equitable reimbursement and preserving physician access.