The Barbarians are at the gate with unbridled avarice ready to plunder and pillage.
By Doug Aldeen
Anthem alleges in a recent lawsuit that providers and their third-party biller ( HaloMD) are abusing the No Surprises Act arbitration process to receive higher out-of-network payments in violation of the federal Racketeer Influenced and Corrupt Organizations (“RICO”) Act, the Employee Retirement Income Security Act, and California’s Unfair Competition Law, among other legal requirements.
The complaint alleges that fraudulent use of the IDR process creates significant incentives for providers to leave, or otherwise remain out of, plan networks. When IDR awards exceed INN payment rates (as represented by the QPA), the system over-compensates out-of-network care across specialties. One study determined that in 2023 median awards were 372% of the QPA. This dynamic has persisted with median payment determinations in 2024 equaling 445% of the QPA. Of particular relevance here, in disputes filed by HaloMD, the median award amount was 934% of the QPA. These examples are not isolated. Recent CMS data makes clear that, in provider-won outcomes, prevailing offers can substantially exceed the plan’s QPA. For instance, for items and services under $100, the median prevailing offer relative to the QPA was 591% in the first half of 2025. The same CMS data also show the median prevailing offer as a percent of the QPA for neurology and neuromuscular procedures equaling 2862% of the QPA – with these claims totaling 52,641 in the second quarter of 2025 alone.
Sunday Morning Bathroom Read Takeaway:
The Barbarians are at the gate with unbridled avarice ready to plunder and pillage. At this moment in time, NSA/IDR claims data might arguably be the most valuable piece of information to a plan sponsor that is publicly available.
