A Bill to End Arbitration, a Senator Racing the Clock, CMS meets with the arbitrators, and a QPA Formula That Just Expired
Congress came back from recess, and the No Surprises Act was immediately back in the headlines. A senior House Democrat introduced a bill that would eliminate IDR entirely. The retiring chair of the Senate HELP Committee says he wants a narrower deal before he leaves. CMS called every arbitrator in the country to Washington. And the carriers’ favorite QPA formula lost its legal cover on October 1. Here is what each of those developments means for your practice, plus a New Jersey PIP change with a comment deadline this week.
Pallone Bill Would End IDR and Let Carriers Set the Rate
On October 8, Representative Frank Pallone of New Jersey, the ranking Democrat on the House Energy and Commerce Committee, introduced the “Lower Premiums, Faster Payments Act”. The name is doing a lot of work. What the bill actually does is eliminate the Independent Dispute Resolution process for all items and services furnished on or after January 1, 2028, including air ambulance.
In its place, the out-of-network rate would simply be the Qualifying Payment Amount, the number the carrier calculates itself. Payment would be due within 30 days of the bill, with no penalty or interest if the carrier misses the deadline. The QPA itself would be rebased to each plan’s median contracted rate as of January 31, 2019, then grown by the general consumer price index, not medical inflation. And the bill explicitly states that there shall be no judicial review of the QPA methodology.
Put those pieces together and the picture is clear. The carrier calculates the benchmark, pays the benchmark, and nobody can second-guess it. The only independent check on lowball payments disappears. Every incentive to contract at fair rates vanishes when out-of-network pays the same median rate anyway. And a 2019 base year plus CPI locks in rates that already trail the cost of running a practice.
This is the benchmark approach Pallone wanted from the beginning. In July 2019, he moved the original No Surprises Act through Energy and Commerce with a median in-network benchmark at its core. After physician pushback, arbitration was added and the law that finally passed in December 2020 had open IDR and no benchmark. Providers won the structure, and Pallone signed on anyway. Six years later, he is reintroducing the benchmark he could not get the first time.
Pallone’s press release leans on a set of numbers being hammered home by insurance carrier propaganda. But those figures leave out the stark truth – carriers failed to participate and lost by default on 24.5 percent of IDR line items in 2025. Awards run high because offers run low. The carriers are the ones causing the problems and then screaming for the system to be changed because of all its problems.
Cassidy Wants an NSA Deal Before He Leaves the Senate
Meanwhile, Senator Bill Cassidy, the retiring chair of the Senate HELP Committee, held bipartisan roundtables in September and has publicly stated that he wants to put out legislation before his term ends. His quote: “Believe it or not, there’s common ground there.”
The stated focus is narrow, which is good news. The two items apparently on the table are 1) the screening of ineligible disputes before they reach arbitration and 2) enforcing timely payment of awards. The likely moving vehicle is a year-end health package in the lame-duck session. Government funding runs out December 11, and several health programs expire December 31, so there will be a must-pass bill moving. The hope would be that Cassidy’s bill gets attached to a much larger moving vehicle like that.
CMS Summons All 17 Arbitrators: Read the Framing Carefully
On October 1, CMS Administrator Dr. Mehmet Oz and Labor Assistant Secretary Daniel Aronowitz met with every certified IDR entity. CMS’s own description of the purpose was to address “increasingly high IDR-associated costs,” and its readout observed that the process “was expected to reduce net costs” to the healthcare system. More than 7 million disputes have been filed since April 2022.
CMS named three concerns raised by users of the process: ineligible disputes, unclear determination rationales, and delayed payment or nonpayment after determinations.
The cost framing and two of the three concerns track the carriers’ propaganda campaign about ineligibility and arbitrators with the wrong incentives. That is not a good sign for providers. The one bright spot is that CMS included a discussion on the nonpayment after awards on its own list. That is a provider friendly issue, and one for which CMS bears some responsibility.
QPA Enforcement Relief Expired October 1: Now what?
Since 2023, the Departments have let carriers keep calculating QPAs under the 2021 formula the courts struck down. The last extension of that enforcement relief, in FAQs Part 73, covered services furnished before October 1, 2026. No further extension has been issued.
That matters because of what the Fifth Circuit did in August. On August 11, the full court held the 2021 formula unlawful. Ghost rates, meaning contracted rates for services a provider never actually performs, are out. Bonus, incentive, and risk-sharing payments are in. Single-case agreements stay out.
In theory, QPAs should now move up, initial payments should move up, and provider offers should look closer to the QPA in every IDR submission. In practice, the Departments have not issued post-decision guidance. Nobody knows yet whether corrected QPAs apply to older claims, how often a provider must furnish a service before its rate counts, or how strict the compliance timeline will be.
The reality is that while the “new QPA” theoretically helps providers, any immediate changes are going to be minimal or invisible until CMS publishes its roadmap.
New Jersey PIP: Daily Maximum Becomes a Weekly Maximum
Closer to home, the New Jersey Department of Banking and Insurance gave advance notice on October 1 that it intends to amend N.J.A.C. 11:3-29.4(m), the PIP fee schedule rule for Physical Medicine and Rehabilitation CPT codes.
Today the rule caps those services at a $105 daily maximum, no matter how many providers treat the patient that day. The proposal replaces it with a $1,015 weekly maximum, Sunday through Saturday, which works out to a $145 daily rate applied over seven days. The change would allow same-day treatment from different providers for the same accident and allow additional procedures.
We view this as a positive change. It raises the cap and makes multi-specialty treatment on the same date of service workable.
Comments are due by October 15, 2026 to AdvanceNotice@dobi.nj.gov.
If you treat auto accident patients, tell the Department you support the weekly cap. We are happy to help you draft a short comment.
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Questions about how any of this affects your practice? Contact James Greenspan at JGreenspan@GottliebandGreenspan.com.
This article is provided for general informational purposes only and does not constitute legal advice.
