As a subtle reminder: my tweets are my own; my employer or trade organizations where I am board member or speaker have nothing to with my tweets or the thoughts expressed therein. #healthlawyertweets

These letters to the WaPo Editors are well stated: "The No Surprises Act is supposed to protect patients. Here’s how it hurts providers. Reforming the No Surprise Act and AI standards, in readers' eyes. October 22, 2026 at 4:29 p.m. EDT Yesterday at 4:29 p.m. EDT Jackson Hammond and Brian Blase’s Oct. 18 op-ed, “A $17 billion surprise bill for Americans,” argued the No Surprises Act’s arbitration system is driving up health care costs, but they missed the root cause driving disputes. I am a practicing emergency physician, and I’ve never met a colleague who said they view arbitration as a business model. But it becomes necessary when insurers terminate network contracts to make lowball payment offers to physicians who treat patients in emergencies, regardless of their ability to pay. The op-ed, which detailed the new Paragon Health Institute analysis, argued that independent arbitrators side with providers in roughly 85 percent of disputes. But that statistic deserves context. In one study, which was backed by the Americans for Fair Health Care coalition, insurers’ qualifying payment amounts were set at $0 in more than 20,000 disputes, and in almost 1,000 others, they were set at less than $1. Meanwhile, more than 20 percent of the time, insurers delayed paying arbitration awards or failed to participate, leaving physicians waiting to be paid for care they had already provided. Paragon argues that physicians use arbitration to demand higher rates. My organization, TeamHealth, has seen awards below what insurers paid for the same services in 2019. Health care systems would rather work under fair, stable in-network agreements, but persistent underpayments make it harder to recruit and retain clinicians and negotiate sustainable contracts, contributing to narrower networks and reduced access to emergency care. Congress should preserve the No Surprises Act’s patient protections, require insurers to comply with arbitration decisions and address the payment practices that make arbitration necessary. Jody Crane, Richmond The writer is the chief medical officer for TeamHealth." Letter #2: "Every single day in America, someone experiences a life-threatening event that requires an air ambulance to keep them alive and get them to a hospital that can provide the appropriate level of care. Teams of dedicated medics, nurses and pilots are on duty 24/7 to respond to emergencies. But these services are critically undervalued by health insurance companies. As important as the No Surprises Act is for protecting patients, it lacks the enforcement mechanisms needed to ensure emergency care providers are reimbursed. Unfortunately, a growing number of payers are refusing to pay the outstanding claims that independent arbitrators have determined they owe — decisions which are legally binding and must be paid within 30 days. To date, insurers owe my company, PHI Health, more than $50 million in unpaid independent dispute resolution awards for emergency care already delivered. This enormous burden has forced us to suspend operations at one base in rural California and threatens the future of air ambulance services. Insurers’ failure to respect the law could eventually leave many communities without air medical services, a situation Congress hardly intended. The No Surprises Act needs more teeth to ensure that insurance companies follow the law and that claims owed are paid promptly. Paul Julander, Tempe The writer is co-president of PHI Health."

To the discussion on healthcare affordability and the $20.4B in net profits posted by only 2 for profit health plans for Q1-3 of ‘26 (w/ more profits coming in Q4), @AnthemBCBS & @UHC, @WSJ quoting a @KFF study is showing the average health insurance cost to a family in ‘26 will be $28K, 5% increase for employers w/ employees’ cost rising 9% from ‘25. While I have said it many times and will continue to do so, there is plenty of $ in the healthcare system—the issue is that it is misdirected from clinicians and hospitals providing the care. share.google/fVVG4zg62WlwGRi…

Make no mistake, the physician, hospital and supporting advocacy community is engaged in a "David v. Goliath" battle to prevent repeal of the #NoSurprisesAct. The community was one when we defeated the health plans in '18, '19 and early '20 and we will have to come together with one voice again. One recalls the famous proverb: "It is not the size of the dog in the fight, it's the size of the fight in the dog." "Health Care Companies Are On Defense. It’s A Windfall For K Street. POLITICO| Amanda Chu | October 21, 2026 (excerpts below) Lobbyists and policy analysts said efforts to prepare companies for oversight in a likely Democratic-controlled House, advance proposals in a year-end legislative package, and rethink the No Surprises Act will dominate the agenda for the remainder of the year.... Congress passed the No Surprises Act in 2020 to address out-of-network bills patients received after emergency care, but it has led to outsized claims. The effort to rewrite it has embroiled doctors and insurers. There were approximately 158 lobbying registrations related to the law in the third quarter, up 52% year over year, according to an analysis of public lobbying disclosures by Baron Public Affairs, a government relations consultancy.... “This has become one of the main health care policy arenas, if not the main one,” Riley Kruse, a director at Baron Public Affairs, said of the No Surprises Act.... UnitedHealth, the largest U.S. health insurer, reported $2.1 million in third-quarter lobbying spending, its highest for the period on record. Its peers Centene, Cigna and Humana also reported elevated spending, with Humana recording its highest year-to-date spending for the period..... "Q3 was my busiest part of the year without question,” said Miranda Franco, senior policy adviser at law and lobbying firm Holland & Knight, the country’s largest health care law practice, which counts hospitals, drugmakers and physician groups as clients. "It’s the second year of this administration, which means that a lot of the proposals and policy agendas are really taking hold,” said Franco, who is tracking proposed rules spanning the Medicare physician fee schedule and the implementation of the One Big Beautiful Bill Act, President Donald Trump’s domestic policy package that cut nearly $1 trillion in future Medicaid spending.... Lobbyists told POLITICO they expect the scrutiny to continue regardless of the midterm results, which will determine control of Congress. “The pharmaceutical industry is under increasing bipartisan pressure on pricing…The threats are coming at them from all sides,” said a lobbyist for large drugmakers, granted anonymity to speak about their client work.... AHIP, the trade group for insurers, spent $3 million on third quarter lobbying, on par with the prior quarter. Year-to-date spending has surpassed $11.3 million, the group’s second highest for the period behind last year. Chris Bond, a spokesman for AHIP, said it continues to “actively engage with policymakers in support of affordable, high-quality coverage options” and blamed hospitals and drugmakers for high costs. Spending at the American Hospital Association, meanwhile, is down. The trade group spent $3.8 million on lobbying in the third quarter, its lowest in at least a decade. The association declined POLITICO’s request for comment. Lobbyists and policy analysts said efforts to prepare companies for oversight in a likely Democratic-controlled House, advance proposals in a year-end legislative package, and rethink the No Surprises Act will dominate the agenda for the remainder of the year. Click here to unsubscribe from these alerts. 📷

More from health lawyer geek-dom (where I consider myself in the front row of the choir)—this announcement sounds good. If a healthcare compliance program has an unintentional issue or negligence, there should be little policy justification for a mandated HHS OIG compliance program over a period of ~5 yrs or so. fiercehealthcare.com/regulat…

Recall that the House bill proposed by Rep. Pallone (D-NJ) (HR 10788 introduced 10/8/26) to "reform" the federal No Surprises Act (NSA) would statutorily bar anyone from challenging the "qualifying payment amount" (QPA or initial payment by the health plan) calculations in court. Instead, presumably the physician, hospital and supporting community would have to rely on audits by CMS of the QPA. As mentioned here last week, there have been over 20+ audits pending by CMS of the QPA calculations for 3-4 years and one had been issued. That one CMS audit found that the health plan had incorrectly calculated the QPA. Now we have 2 more QPA audits--CareSource offers fully insured group health insurance coverage and the School Employees Retirement System, Ohio (Ohio SERS) is a self-funded nonfederal gov't plan that uses Aetna as its TPA. Two CMS/CCIIO audits illustrate distinct QPA risks: CareSource substituted usual-and-customary rates for contracted-rate medians, an express violation; Ohio SERS excluded negotiated rates associated with contracts that generated no claims, an issue commonly described as “ghost rates,” but CCIIO classified it only as an observation following TMA III litigation. The physician, hospital and supporting advocacy community has contended for years since the implementation of the NSA on 1/1/22 that the QPAs were not calculated in compliance with law including the +28% inflationary mandate required by the NSA and regulations. These audits are now independent verification of those contentions. So, presumably, had the Ohio SERS audit been done after the TMA III en banc US Court of Appeals for the Fifth Circuit ruling in August, 2026, ruling and new regulations by CMS, that ghost rates could not be included in the QPA, hypothetically then that finding in Ohio SERS could have been an express violation as well. Both entities were also cited for failing to provide required NSA notices and disclosures (referred to as QPA disclosures). So, the health plans are now 0-3 in QPA audits but Mr. Pallone would have us wait years under his bill for audits to be completed while the health plans have unilateral and unfettered ability to set and implement the QPAs as they see fit with little to no consequence for their non-compliance--sounds like a "health plans win/we lose" situation. cms.gov/files/document/qpa-f… cms.gov/files/document/qpa-f…