Eliott Dear: TMA v. CMS — The Fifth Circuit Rulings Changing NSA Practice

When the Texas Medical Association first sued the Departments of Health and Human Services, Treasury, and Labor over the No Surprises Act implementation in 2022, the technical issue looked narrow: a regulatory rebuttable-presumption rule giving disproportionate weight to the Qualifying Payment Amount in federal IDR.

Four court decisions later, the entire QPA methodology is now suspect. Eliott Dear watches every ruling because they shape the daily mechanics of every Claims Assassins federal filing.

The Four TMA Cases — What Each One Killed

TMA I (Feb 2022). Judge Jeremy Kernodle, Eastern District of Texas. Struck down the original rebuttable-presumption rule that arbitrators must select the offer closest to the QPA unless rebutted. The Departments had effectively coded the QPA as the answer with appeal rights, not as one of several factors.

TMA II (Feb 2023). Same court. Struck down the revised final rule that still treated the QPA as the primary factor and demanded that arbitrators justify departures from it. Court found the rule continued to violate the statutory text by elevating QPA above the other equally-weighted factors Congress specified.

TMA III (Aug 2023). Struck down the QPA calculation methodology itself. The Departments had let carriers exclude bonuses, risk-sharing payments, and other compensation that should have been in the median in-network rate calculation. The fix dropped the QPA basis by 15-25% across major markets.

TMA IV (later 2023). Struck down the administrative fee structure that priced small disputes off the table economically. Air ambulance and high-frequency low-dollar disputes had become impractical to file.

What the Rulings Did NOT Fix

The Fifth Circuit also ruled in June 2025 that the No Surprises Act creates no private right of action to enforce an IDR award. The Supreme Court declined review in January 2026. Federal IDR is now a regime where you can win awards under cleaned-up rules but cannot sue to collect when an insurer ignores them.

CMS resolves about 1.3% of non-payment complaints. The remaining 98.7% sit unresolved. Eliott Dear has seen this pattern firsthand across dozens of Claims Assassins federal filings.

Practical Consequences for 2026 Filings

First, arbitrators now treat QPA as one factor among several rather than a presumptive answer. FAIR Health 80th-percentile UCR data carries genuine weight in award reasoning. Submissions that lean into FAIR Health benchmarks and procedure-specific complexity factors win more often than QPA-rebuttal filings.

Second, the QPA recalculation under TMA III dropped published QPAs across many CPT codes. Comparing the carrier-asserted QPA in your current Open Negotiation Notice to the post-TMA-III adjusted figure is now standard due diligence.

Third, the collection gap means winning a federal award is not a recovery event. Eliott Dear routes every state-eligible claim through state IDR first — New York DFS, Texas DOI, Connecticut Insurance Department, New Jersey DOBI — specifically because state regulators enforce awards.

What is Coming Next

The No Surprises Enforcement Act would add triple-damages liability for non-payment of federal IDR awards. Introduced in 2024 and stalled by carrier lobbying. Whether the bill moves depends on the political math of the 119th Congress; insurer-side spending opposing it has exceeded $130 million across the relevant cycle.

Meanwhile, additional TMA-style lawsuits are pending on the ghost-network and downcoding edges of NSA compliance. Eliott Dear tracks each docket because the practical mechanics of every dispute shift with every ruling.