'CRAZY' … 'WAY OUT OF LINE' … 'NOT SUSTAINABLE': NYT INVESTIGATION UNCOVERS OUTRAGEOUS PROVIDER-DRIVEN ABUSES OF THE NO SUPRISES ACT

The following information was released by the America's Health Insurance Plans (AHIP):

Yet another investigative report is pulling back the curtain on growing abuse of the No Surprises Act by out-of-network providers and IDR middlemen who flood the law's arbitration system with ineligible claims and extract outrageous overpayments to maximize their own profits at Americans' expense.

"A law meant to end surprise medical billing has led to large paydays for some surgical assistants, who can earn far more than the doctors they help," The New York Times finds in a report titled "$22,000 Per Hour: Assistants Use a Legislative Loophole to Outearn Surgeon."

Highlights from the Times' investigation include:

"For those services, the standard fee paid by most health insurers is 16 percent of the surgeon's earnings. But across the country, assistants are sometimes earning up to 25 times what the doctor makes, according to data reviewed by The New York Times and interviews with officials who manage large health plans. They do it by capitalizing on a law intended to protect patients from surprise billing by providers not in their insurance plan. Under the law, those providers can file for arbitration, where they are able to make a case for much higher payments than they could otherwise receive from health plans."

"In March, for example, a surgical assistant in Dallas earned $50,456 through arbitration for a prostate removal operation. The surgeon, who accepted the patient's insurance, earned $1,843. The assistants outearning primary surgeons are sometimes doctors but more often nurses or physician assistants."

"For assistants to regularly be able to earn so much more than the main surgeon 'is crazy,' said Brady Connaughton, a lawyer in New Jersey who advises union health plans. 'It's a very blatant disregard of both the spirit of the law and what the law says,' she said."

Luis Aragon, chief executive of Illinois-based Surgikal Assistants acknowledged the "very large awards for assisting are signs of a system gone awry. '$100,000, $50,000, all these amounts are way out of line,' he said. 'And that is not sustainable for health care costs.'"

"Legislators who wrote the No Surprises Act were focused on protecting patients in emergency situations. But many cases now going to arbitration involve operations scheduled far in advance..."

"Some in-network surgeons appear to team up often with the same out-of-network assistants. At Lenox Hill Hospital in Manhattan, Dr. Shari Reitzen-Bastidas frequently assists Dr. Nicholas Bastidas, her husband, on operations to make transgender women's faces look more feminine. She has repeatedly earned six to 224 times as much as him, according to records reviewed by The Times. In one instance, arbitrators awarded Dr. Reitzen-Bastidas $210,000 for her work assisting with an operation that involved reshaping bones around the eyes. Dr. Bastidas earned $12,767 for the same case. A partial review of recent cases involving Dr. Reitzen-Bastidas found she had won at least $1.4 million in arbitration as an assistant for such cases since 2025. Dr. Bastidas and Dr. Reitzen-Bastidas did not respond to requests for comment."

"In situations where neither the main surgeon nor the assistant takes the patient's insurance, they often submit separate claims to arbitration and can earn even more. The two cases are often assigned to different arbitrators, who do not know they are connected. A Wisconsin neurology practice received $196,215 for a 2024 spinal fusion operation $125,058 to the main surgeon, Dr. Arvind Ahuja, and $70,707 to his assistant, according to documents reviewed by The Times. Typically, health plans would pay the surgeon $9,310 and the assistant $1,562. The practice split the operation into multiple bills, enabling them to bring 11 separate cases to arbitration, winning all of them. Dr. Ahuja declined to comment."

What AHIP Is Saying: "Outrageous provider-driven abuse of the No Surprises Act is adding billions in wasteful spending and raising healthcare costs for everyone. Policy action is needed to address flawed incentives in the IDR process and protect consumers from unconscionable price gouging by out-of-network providers and IDR middlemen," said Chris Bond, AHIP spokesperson.

What CBO Is Saying: Growing provider-driven abuse led the Congressional Budget Office (CBO) to acknowledge this month that "[e]merging evidence suggests that the law might not have the [savings] effects that CBO anticipated," warning it may cause higher premiums, higher federal deficits and increased anti-competitive consolidation by providers.