How did the TMA lawsuits reshape the federal IDR process, 2022–2026?

The short version

The No Surprises Act tells a certified IDR entity to consider the QPA and, alongside it, additional circumstances such as provider experience, market share and patient acuity (42 U.S.C. 300gg-111(c)(5)(C)). Each round of federal rules that tilted that weighing toward the QPA, or that affected how the QPA itself is calculated, was challenged in the Eastern District of Texas by the Texas Medical Association, joined by Tyler Regional Hospital, Dr. Adam Corley and, in some cases, air ambulance providers. In each case the challenged provisions were vacated, at least in part.

Case by case

Numbering follows the Departments' usage in the 2026 Federal IDR Operations rule (91 FR 33900, 33901 n.9).

TMA I and II: the QPA loses its head start

TMA I held that the October 2021 presumption conflicted with the statute, which requires arbitrators to consider both the QPA and the additional circumstances, and that the Departments skipped notice and comment. The Departments' August 2022 final rule replaced the presumption with instructions that IDR entities consider the QPA first and give weight to other information only if it was credible, related to an offer and not already reflected in the QPA. The district court found that these provisions "place a thumb on the scale for the QPA." The Fifth Circuit affirmed on August 2, 2024, "tracking in large part the district court's able opinion," and upheld universal vacatur as the remedy.

TMA IV: fees and batching

In TMA IV the district court vacated the December 2022 guidance that raised the per-party administrative fee from $50 to $350 for 2023, along with batching provisions, and the Departments did not appeal (110 F.4th 762, n.11). The Departments later set the fee at $115 by rulemaking for disputes initiated from January 22, 2024, and at $15 for disputes initiated from June 11, 2026. The 2026 rule also adopts new batching categories and a 50-line-item limit.

TMA III: what goes into the QPA

TMA III went to the core number. A Fifth Circuit panel largely sided with the Departments on October 30, 2024 (120 F.4th 494), but the full court granted rehearing on May 30, 2025, vacating that opinion. On August 11, 2026, the en banc court held:

• Ghost rates. The July 2021 rule unlawfully required insurers to count every contracted rate, including non-negotiated rates for services a provider never furnishes. The statute limits the QPA to items or services "provided by a provider."
• Incentive payments. Excluding bonus, incentive and other retrospective payments conflicted with the statute's "total maximum payment" language.
• Single-case agreements. Excluding one-off agreements, common in air ambulance, was lawful.

On remedy, the court affirmed vacatur as the default under the APA, rejecting what it called a "too-big-to-vacate principle." It noted the district court's observation that agencies "can exercise their enforcement discretion to allow insurers to continue using their existing QPAs until new QPAs are calculated consistent with the Act."

The operational cost

The Departments state that the district court's successive rulings "necessitated multiple temporary shutdowns of the Federal IDR process," each requiring new guidance, rulemaking and system updates (91 FR 33902).

The outcome data the courts cited

The en banc majority cited the volume of arbitrations, provider success in over 80% of them and awards above the QPA in 85% as signs that QPAs were artificially low. CMS's most recent figures are similar: providers prevailed in about 85% of payment determinations from July 1 to December 31, 2025, and the prevailing offer exceeded the QPA in about 87%.

What remains open

The en banc court remanded TMA III for further proceedings. The opinion does not set a timetable for recalculated QPAs, and the Departments' 2026 rule, published before the en banc decision, describes the district court's August 24, 2023 judgment as binding them pending that decision (91 FR 33901).