Health insurers have a new talking point – based on a new “study” by the giant health insurance conglomerate Elevance Health – and it goes something like this: Doctors are exploiting the No Surprises Act’s (NSA) arbitration process to extract outrageous payments, and something must be done before the whole system collapses under the weight of runaway awards.
I spent two decades inside the health insurance industry, long enough to recognize a deflection campaign when I see one. I contributed to and promoted more studies like Elevance’s than I can remember. The objective of all of them was to influence public policy in ways that would benefit health insurers. You could always count on the methodology to be suspect and important data and information to be withheld to achieve that objective.
Let me be clear about something before we go further, though. There are bad actors in every corner of health care, and the No Surprises Act’s arbitration process is no exception. A small number of billing intermediaries have built businesses around submitting disputes for arbitration, chasing large awards rather than fair payment. That behavior is real, it deserves scrutiny, and it deserves to be fixed. Nobody serious about protecting patients — the main objective of the NSA – should defend it.
Court Rejects Anthem’s Attempt to Relitigate Arbitration Losses Under No Surprises Act
Judge Karen Scott dismisses federal claims against HaloMD, signaling that insurers can’t use RICO and ERISA suits to bypass the law’s dispute resolution process.
But that is not what Elevance Health’s new study is about.
The study, released by Elevance’s Public Policy Institute in late June, looked at roughly 7,300 payment disputes involving procedures that are typically scheduled in advance, like spine surgery and colonoscopies. For reference, the study included fewer than 1% of disputed claims submitted in the arbitration process. According to the Institute’s report, providers won nearly 90% of those disputes, with some awards running well above what insurers call a fair benchmark. Even though a very small fraction of the disputes were examined, Elevance’s message to Washington was broad: The entire arbitration process has spiraled out of control, and it is your problem to fix.
Here is what they conveniently left out: If an insurer’s initial offer, and the qualifying payment amount (QPA) it uses to justify that offer, is unreasonably low to begin with, then of course arbitration produces a large award relative to that number. That is not evidence the process is broken. That is evidence the insurer’s offer was never made in good faith.
Here’s an example. CPT 99285 is an emergency department code used for the most serious cases, including heart attack and stroke. Government data shows insurers used QPAs of under $1 for this code, including as low as 1 penny.
How Insurers Are Using the Courts to Rewrite the No Surprises Act
A wave of coordinated lawsuits is transforming the No Surprises Act’s arbitration system into a battlefield where insurers seek to intimidate physicians, rewrite the law and consolidate control.
Consider another case that came across my desk recently: a patient’s breast implant procedure. The insurer’s own benchmark payment rate was $111,000 for the procedure, but the insurer’s payment offer was zero. It did not negotiate at all. It let the claim go to arbitration, lost, and now that loss gets counted as an outlier in a study designed to make the doctor look like the problem.
That is the story Elevance does not want anyone to look at too closely. And there is a reason for that.
As we have reported, Arizona’s attorney general last month sued MultiPlan and eight of the nation’s largest health insurers, Elevance included, alleging they used a shared pricing algorithm and pooled competitively sensitive claims data to suppress what they pay for out-of-network care across the industry, rather than competing with each other honestly.
According to the complaint, MultiPlan collected a fee based on how much it saved insurers by pushing payments down, and insurers in turn charged self-insured employers their own shared savings fee for the same maneuver. The lower the payment to the doctor, the more money changes hands–for everyone except the physician who did the work.
That case joins a federal antitrust action already in discovery, with the Department of Justice weighing in on the side of providers, and a separate class action accusing an insurer of shortchanging claims specifically because doing so increases the savings fee it can charge employers.
No Surprises, But Plenty of Abuses: How Insurers Are Pulling the Strings on the No Surprises Act
The No Surprises Act, passed with good intent, is now being twisted against patients and doctors by big health insurance companies.
Stated perhaps more plainly, the insurance industry’s position is that when doctors use a legal process to challenge lowball insurer offers and win, that is a crisis requiring immediate policy intervention. But when insurers allegedly coordinate with a vendor to suppress payments across the board and collect a fee for doing so, that is a pending legal matter best discussed quietly, far from the op-ed page.
That’s not an accident. That’s a strategy: Manufacture a crisis on one side of the ledger loud enough, and regulators stop asking hard questions about the other side–the side that would have reputational and likely legal ramifications for those same insurers.
None of this means the arbitration process is perfect. It is not, and the small number of bad actors gaming it deserve exactly the same scrutiny I am applying to insurers here. But the vast majority of physicians who go through this process are not running a racket. They are simply doctors and small practices who, after caring for patients, received a payment offer well below fair value and used the process Congress gave them to make their case in front of an independent arbiter–and won. Painting all of them with the same brush as the worst offenders is not a data-driven concern about program integrity. It is a sneaky public relations strategy, and a fairly transparent one at that.
If insurers want a serious conversation about who is gaming the No Surprises Act, I am all for it. But that conversation has to include the party currently facing a state antitrust lawsuit for allegedly rigging out-of-network payments in the first place. Anything less is just insurers grading their own homework.
Incremental piecemeal laws like the “No Surprises Act” (passed in 2020) continue to fail patients.
(Elevance Health's Public Policy Institute. That's funny.)
For those who skim, read Wendell's full article >
Gail Boudreaux should be indicted, convicted and incarcerated by now.
Elevance paid the government more than $342 million to help settle allegations that it overcharged the federal healthcare program for years. Elevance sent the money to the Centers for Medicare & Medicaid Services via wire transfer on May 27, 2026, court records show.
Just days later on June 1st, Attorney General Kris Mayes announced a lawsuit against MultiPlan and several large commercial health insurance investment banks, alleging they quietly built and operated a system that slashed payments to doctors and hospitals — and left Arizonans having to pay more for out-of-network care. The lawsuit alleges that for years, MultiPlan and insurers Aetna, Cigna, UnitedHealthcare, Humana, Elevance, Molina, Centene, and Health Care Service Corporation relied on a shared algorithm to decide how much to pay for out‑of‑network care, which relied in part on their collective sharing of confidential, competitively sensitive claims payment information with and through MultiPlan. Instead of competing or setting payments independently, they allegedly used the same formula and the same data, and delegated payment negotiation decisions to MultiPlan, resulting in extremely low payments across the industry that continued to decrease over time.
The commercial health insurance investment banks collude to architect crimes. This is price-fixing. Physicians attended the presser in Arizona to underline how much harm these crimes impose on physician practices and patients. These are not victimless crimes.
The corporatization of medicine has caused preventable harm and death for 40 years. The only solution to the failed approach to, and model of, healthcare policy in the United States of America is to pass Senate Bill 1506/HR 3069 — National Improved Medicare for All / Single Payer Universal Healthcare.
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The statistic that providers prevail in roughly 90% of IDR disputes is technically accurate. But standing alone, it is also deeply misleading.
The far more important statistic is this: fewer than 5% of IDR eligible claims ever make it to arbitration.
That means insurers’ payment determinations stand on more than 95% of eligible claims without any independent review whatsoever.
So when insurers point to a 90% provider win rate, they are not describing the No Surprises Act as a whole. They are describing the tiny fraction of claims that survive a long, expensive, and administratively burdensome process to reach an independent certified IDR entity.
That distinction matters.
If providers were broadly “gaming” the system, we would expect far more than 5% of eligible claims to be submitted to IDR. Instead, most providers accept underpayments because pursuing arbitration requires filing fees, significant documentation, administrative resources, and the risk of losing.
The claims that do reach IDR are therefore not representative of all claims. They are the claims where providers believed the insurer’s payment was so unreasonable that the economics justified seeking independent review.
There is another piece of the story that rarely gets mentioned.
A significant number of provider “wins” occur because the insurer never submits an offer or otherwise fails to participate in the IDR process. Those determinations are not the result of an arbitrator choosing one well argued offer over another. They occur because one party chose not to participate in the process Congress established.
Those default determinations are then combined with fully contested cases and cited as evidence that providers are somehow exploiting the system.
That raises an important question.
If insurers truly believe these claims are defensible, why are so many allowed to result in default determinations?
The more important question is this.
When insurers do participate, and an independent certified IDR entity reviews both parties’ offers using all of the statutory factors Congress required, not just the QPA, why are insurer offers rejected so frequently?
Is that evidence the process is broken?
Or is it evidence that the relatively small number of claims reaching IDR are precisely the claims where insurers’ payment offers were least likely to withstand independent scrutiny?
If we are going to evaluate the No Surprises Act honestly, we have to look at the entire process.
Insurers prevail on more than 95% of eligible claims before any independent review ever occurs.
Only a tiny percentage of claims reach arbitration.
Some of the provider wins within that small percentage occur because insurers never participate.
Without that context, citing a 90% provider win rate is not a complete analysis.
It is a carefully selected statistic that tells only part of the story.