NYT: PROVIDER-DRIVEN ABUSE AN 'EXPENSIVE UNANTICIPATED CONSEQUENCE' OF NO SURPRISES ACT

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

by AHIP

Yet another investigative report is shedding new light on how some providers and middlemen are abusing the No Surprises Act at Americans' expense, padding their own profits while driving up health care costs for everyone.

"Doctors have flooded the arbitration system with millions of claims. Most are winning, often collecting fees hundreds of times higher than what they could negotiate with insurers directly or what they could have earned from patients before the law passed," the New York Times reports:

"Arbitrators have repeatedly approved doctors' submissions of extremely high prices for common medical procedures ... A neurosurgery practice outside of Philadelphia went to arbitration after the health plan Highmark offered its standard payment of $2,660 for a diagnostic procedure to measure blood flow to the brain. An arbitrator awarded it $333,000 instead."

"Medical specialties like spinal and plastic surgery, for which surprise bills were rare before the law, now frequently have cases in arbitration ... Some practices are using the law to obtain high payments for routine medical care, including gynecologists who have won fees 600 times higher than usual rates for placing intrauterine contraceptive devices, or I.U.D.s."

"Many claims that shouldn't be eligible for arbitration, such as those for patients covered through the government programs Medicare and Medicaid, move through the system anyway."

"Some argue that because the arbitrators are paid per case, they may have an incentive to render decisions that keep doctors coming back ... The arbitrators are doing well too. The fees they earn for deciding cases, which range from $425 to $1,150 per case, have added up. They earned $885 million from 2022 to 2024."

"The United Service Workers health plan, which covers 20,000 trades workers in the New York area, said it boosted premiums by an extra 1.75 percentage points to offset arbitration awards and fees."

The Times investigation adds to a growing body of evidence that persistent provider-driven abuse of the arbitration process is adding to the health care affordability crisis. A recent STAT investigation found that some middlemen, mostly backed by private equity, have "flood[ed] the overburdened federal arbitration system with thousands of disputes" to fund "lavish" lifestyles. A Health Affairs analysis estimates that the high volume of claims submitted by a handful of bad actors have led to $5 billion in wasteful spending.

As one lawmaker who sponsored the No Surprises Act says in the New York Times report, "we need to rein in this arbitration process." Health plans support common-sense solutions to do just that, including:

Strengthening enforcement to ensure only eligible claims enter the IDR process

Requiring transparency in arbitration decisions and clear rationale for awards

Penalizing serial abusers by limiting IDR access for organizations that repeatedly submit ineligible claims