“Awards usually land at 3–10× the toilet-paper number. But sometimes it’s 100× or 150×”
By Sina C. on Linkedin
The “No Surprises Act” made it illegal for healthcare providers to surprise balance bill everyday patients. Docs and insurers have to duke it out like Blake Lively and Justin Baldoni. If they can’t come to terms, they go to the federal Independent Dispute Resolution process (IDR).
Congress projected ~20K cases a year. 2025 delivered over 2.5 million disputes. Congress just crushes it again. Let’s go, Congress.
In these disputes, providers win ~85%. Usually because the insurers stonewall with an offer based on the “Qualifying Payment Amount”—basically toilet paper that says “I don’t want to pay you.” So the arbitrator goes, “Ok—we’ll go with the doctor’s number.”
Awards usually land at 3–10× the toilet-paper number. But sometimes it’s 100× or 150×. Nearly $15 billion paid out last year. Excess and fees cascade into premiums. Volume still accelerating.
A handful of operators are treating the healthcare system like an ATM. Horizon Blue Cross Blue Shield of New Jersey has sued Alteva RCM (formerly M&D Capital).
The complaint is like a script for a mafia operation: flooding the system with claims it knew were ineligible under New Jersey’s state out-of-network law, coaching providers to jack billed charges into the stratosphere, surgically carving single surgeries into as many as ten separate claims (like Ticketmaster turning one ticket into the ticket + convenience fee + facility fee + service fee + a charge just for existing… oh wait), skimming an 18% contingency cut of every inflated dollar, and stamping false eligibility attestations onto the physicians’ names and risk.
One example: a breast-reduction service billed ~$161k walked away with a $150k IDR award—roughly 100 times the state process payment. $150K for a 3-4 hour surgery… about the MSRP of a new 2026 Porsche 911 Carrera T.
Most out-of-network physicians remain genuinely underpaid. The great majority never even file and simply absorb the low initial payment. The independent doctors need help. Their clean claims now sit buried behind this casino while we all pay for the excess.
This is classic tragedy of the commons: a handful of actors farming a broken process at industrial scale… and the problem seems to be getting worse.