How Insurers Are Using the Courts to Rewrite the No Surprises Act

By Wendell Potter – As I have written, Congress passed the No Surprises Act (NSA) to safeguard patients from unforeseen medical expenses and establish a neutral, independent dispute resolution (IDR) process for payment conflicts between insurers and out-of-network providers. That design was meant to replace brinkmanship with an independent referee. What Congress designed as a neutral arbitration system is now being challenged by Big Insurance through coordinated litigation designed to narrow, intimidate, and ultimately reshape the law. Read Full Article... 

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1. Insurers File Coordinated Lawsuits Over IDR Use: Several major insurance companies, including UnitedHealthcare, Elevance/Anthem affiliates, and Blue Cross Blue Shield plans, have filed a series of federal lawsuits against healthcare providers, hospitals, and revenue-cycle management companies that frequently use the No Surprises Act’s Independent Dispute Resolution (IDR) process. The lawsuits contain similar legal arguments and allegations, often claiming that providers submitted excessive or ineligible IDR disputes and misused a system intended to resolve billing disagreements. Critics argue the cases function as a coordinated strategy to discourage providers from relying on IDR to challenge insurer payment decisions.

2. Dispute Over IDR Volume and Payment Benchmarks: Insurers claim the large number of IDR disputes indicates system abuse, citing government projections that initially expected far fewer cases than have actually been filed. Providers and some analysts argue the projections were based on flawed assumptions and that higher volumes reflect widespread disagreements over insurer payment levels and benchmark calculations such as the Qualifying Payment Amount (QPA). Federal data cited in the debate shows that a majority of disputes submitted for arbitration have been deemed eligible by independent reviewers, highlighting ongoing disagreement over whether high dispute volume reflects misuse of the system or payment disputes.

3. Potential Legal Precedents Could Affect Provider Participation: Some lawsuits seek court rulings that would allow insurers to challenge IDR eligibility decisions outside the arbitration process and potentially pursue fraud claims related to disputes deemed ineligible. Supporters say such measures could deter improper filings and clarify the rules governing arbitration, while critics warn they could increase legal risks and costs for physician practices that use the process to contest payments. Policymakers and healthcare stakeholders are closely monitoring these cases because their outcomes could influence how the No Surprises Act’s dispute resolution system functions and affect the balance of negotiating power between insurers and providers.

Aetna faces no risk of financial loss in health benefits case, federal court rules

By Allison Bell – When a patient sues the administrator of a self-insured health plan for coverage of a procedure, the administrator faces no risk of financial loss and is not entitled to a security bond from a patient who gets a preliminary court ruling requiring the plan to cover the procedure, according to a new federal court decision. U.S. District Judge Victor Bolden looked at whether health plan third-party administrators facing preliminary injunctions can get security bonds from the patients in a ruling on Gordon et al v. Aetna Life Insurance Company. Read Full Article... ^{_{(Subscription required)}}

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1. Aetna Lawsuit Challenges Gender-Related Surgery Coverage Policy: Aetna stated that it supports the LGBTQ+ community and administers benefits based on the terms established by employer-sponsored health plans it manages as a third-party administrator. The company noted that many employers customize their coverage policies for gender-affirming care and that it works with plan sponsors while complying with regulations. Aetna said it strongly disagrees with the allegations in the lawsuit and intends to defend itself.

2. Plaintiffs Seek Coverage for Gender-Related Facial Surgery: The lawsuit was filed by members of self-insured employer health plans administered by Aetna whose employers have not set their own policies for gender-related care. Aetna classifies some gender-related treatments as medically necessary but considers gender-related facial surgery cosmetic and not medically necessary under a clinical policy bulletin. Two plaintiffs, Jamie Homnick and Gennifer Herley, asked the court to block Aetna from applying this policy and argued they should not be required to post a security bond because they cannot afford one.

3. Judge Allows Case to Proceed and Requires Individual Coverage Reviews: A federal judge denied Aetna’s request to dismiss the case, finding that a categorical exclusion of gender-related facial surgery could violate anti-discrimination protections under Section 1557 of the Affordable Care Act. The ruling did not require Aetna to approve the requested procedures but ordered the insurer to make individualized determinations based on medical necessity instead of automatically denying such claims. The judge also denied Aetna’s request for a security bond, concluding there was insufficient evidence the company would suffer financial harm from the injunction.

Joint Economic Committee report: Medicare Advantage overpayments drive up Part B premiums

By Paige Minemyer – Overpayments in Medicare Advantage are likely driving up Part B premiums for seniors, according to a new study from Congress' Joint Economic Committee. The report found that the average MA enrollee costs the federal government 120% of what it would cost to cover that same individual in traditional Medicare. When the program was conceived, it was built on the idea that a Medicare program run by private plans would cost less than the traditional program, the report notes. Read Full Article...

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1. Medicare Advantage Overpayments Estimated at $76–$84 Billion: A Joint Economic Committee report estimates that the federal government overpaid Medicare Advantage (MA) plans by between $76 billion and $84 billion in the previous year. The analysis found that individual beneficiaries enrolled in MA cost about 17% to 20% more to coverthan those in traditional Medicare. The report attributes the higher spending to structural payment differences and practices such as aggressive upcoding and quality bonus payments, which it says contribute to overall program costs.

2. Overpayments Linked to Higher Part B Premiums and Social Security Impact: According to the report, MA overpayments have increased Medicare Part B premiums by an estimated $82 billion since 2016. About $6 billion of that burden has been borne by traditional Medicare enrollees, even though they are not enrolled in MA plans. The report states that approximately 85% of the premium burden falls on beneficiaries themselves, with the remainder shared by states and taxpayers, and notes that many seniors pay these premiums through deductions from their Social Security benefits, reducing take-home payments.

3. Premiums Projected to Double by 2035, With $450 Linked to MA Payments: The committee projects that per-person Part B premiums will rise from about $2,440 to roughly $5,000 by 2035. Of that increase, about $450 per person is attributed to Medicare Advantage overpayments, according to the analysis. The report recommends aligning Medicare Advantage payment levels more closely with traditional Medicare to address affordability concerns and moderate long-term premium growth.

Single Payer 'Hands Down' the Best Way to Solve High Healthcare Costs, Advocate Says

By Kristina Flore and Gregory Laub – In this series, MedPage Today is asking healthcare economists and policy experts the same questions about the high costs of U.S. healthcare. They'll reveal what they believe is working, what's not working, and what else can be done to bring costs down. In this interview, Robert Weissman, co-president of Public Citizen, an advocacy group that works extensively on healthcare, explains why he believes moving to a single-payer system is the only way to reduce healthcare costs in the U.S. Read Full Article... ^{_{(Subscription required)}}

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1. Administrative Complexity Drives Higher Costs: Administrative overhead is identified as one of the largest contributors to higher healthcare costs in the United States compared with other developed countries. The multi-payer private insurance system creates extensive paperwork, billing requirements, and bureaucracy that significantly increase administrative spending. Administrative costs in the private insurance sector are estimated to be almost 10 times higher than those in public programs like Medicare, and roughly 20% of total healthcare spending is attributed to administrative waste.

2. Profit and Technology Contribute to Cost Growth: Profit-seeking in sectors such as insurance companies, pharmaceutical companies, for-profit hospitals, and private equity firms is described as another factor contributing to rising healthcare costs. Increasing use of medical technology, diagnostic tests, monitoring equipment, and high-priced pharmaceutical products also drives spending growth. Some drug prices are reported to be up to 10 times higher than they were not many years ago, even when manufacturing and research costs have not increased at the same rate.

3. Physician Pay Not Seen as Major Cost Driver: Physician salaries themselves are not identified as a primary cause of high healthcare costs. Instead, physicians spend a large portion of their time completing administrative tasks and insurance paperwork rather than providing direct patient care. This administrative burden stems from the complex insurance system, and reducing it could allow physicians to spend closer to 100% of their time delivering care, improving efficiency without significantly affecting overall healthcare spending.

What Americans sacrifice due to high health costs

By Adriel Bettelhelm – Tens of millions of Americans have delayed surgeries, vacation plans, career moves and other big life decisions because of the cost of health care, a new West Health-Gallup survey found. Why it matters: Affordability concerns are hanging over the midterm election cycle, with just over half of all Americans believing basic medical care is affordable and accessible. Read Full Article...

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1. Health Care Costs Drive Financial Trade-Offs: A survey of nearly 20,000 U.S. adults found that only slightly more than half believe basic medical care is affordable and accessible, highlighting ongoing affordability concerns. One in three adults reported making a financial trade-off such as taking out a loan within the past 12 months to pay for health care or medicine. These pressures occur alongside rising costs for essentials like groceries, housing, and utilities, which can strain household budgets even for people with insurance.

2. Medical Expenses Delay Major Life Decisions Across Income Levels: The survey found that about half of households earning between $48,000 and $180,000 annually postponed at least one major life decision in the past four years due to health care costs. Delays were also reported by higher earners, including 34% of adults in households earning $180,000 to less than $240,000 and 25% of those earning at least $240,000. As a result, an estimated 37 million Americans delayed buying a home, 46 million postponed changing jobs, and 40 million abandoned plans to pursue additional education or job training.

3. Delayed Medical Care May Worsen Costs and Health Outcomes: West Health–Gallup estimates that nearly 70 million Americans delayed surgery or another medical treatment during the period studied. Forgoing care can allow health conditions to worsen, which may require more procedures, tests, and medications later. Increased demand for services can then raise insurance premiums or out-of-pocket costs, potentially leading some individuals to forgo coverage altogether and reinforcing concerns that care will become less affordable without significant policy changes.

235,000 affected by cyberattack on largest ambulance provider in Wisconsin

By Jonathan Greig – A prominent ambulance service in Milwaukee confirmed that hackers targeted their systems last year and stole sensitive information on more than 235,000 people. Bell Ambulance, which is the largest ambulance provider in the state of Wisconsin, filed breach notifications in Maine this week confirming that 237,830 people had information impacted by a data breach discovered in February 2025. Read Full Article...

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1. Bell Ambulance Cyberattack Exposed Sensitive Data: A cyberattack on Bell Ambulance resulted in the theft of highly sensitive information, including Social Security numbers, driver’s license numbers, financial account details, and medical and health insurance information. The company discovered the breach on February 13, 2025 and hired cybersecurity experts to investigate and support recovery efforts. Bell Ambulance operates multiple stations across Wisconsin and employs more than 750 people who handle about 140,000 ambulance calls each year, meaning the breach could affect individuals connected to a large regional emergency service network.

2. Medusa Ransomware Group Demanded $400,000 for Stolen Data: The Medusa ransomware group claimed responsibility for the attack and demanded a $400,000 ransom in exchange for 219 GB of data it said it had stolen from Bell Ambulance. The ransomware-as-a-service group first emerged in June 2021 and has since carried out more than 300 attacks on critical infrastructure organizations. Targets have included medical companies, manufacturing firms, and other organizations across the United States.

3. FBI Warns of Widespread Attacks and Advanced Extortion Tactics: About a month after the Bell Ambulance incident, the FBI and other U.S. law enforcement agencies issued an advisory warning about Medusa’s growing attacks on critical infrastructure. Investigators reported that the group has targeted governments and healthcare facilities in states such as Minnesota, Illinois, and Texas, as well as private organizations like NASCAR. In some cases, the group has used “triple extortion” tactics, where attackers demand multiple ransom payments by claiming that a previous payment was stolen and offering a separate “true decryptor.”

Benefits Think My journey from corporate HR to service provider

By Caroline Jessen – In the ever-evolving realm of human resources, people management and benefits, my journey from corporate HR roles to the vendor side has been an enlightening experience, particularly when it comes to the topic of employee benefits. This path has provided me with invaluable lessons that are especially relevant for health insurance brokers and advisers. It has shown me the transformative power of strategic HR leadership and revealed insights gained from navigating both corporate and service-provider landscapes in the benefits arena. Read Full Article... ^{_{(Subscription required)}}

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1. Understanding Employees Improves Benefits Design: Early HR service center experience demonstrated how employee benefits directly influence workplace satisfaction, engagement, and retention. Direct interaction with employees revealed that understanding their needs, concerns, and experiences is essential when creating benefits programs that are truly useful. Benefits strategies that incorporate employee feedback and focus on real workforce priorities are more likely to be effective and valued.

2. Simplicity and Clear Communication Increase Benefits Value: Overly complex benefits offerings can lead to confusion, low participation, and underutilization among employees. Prioritizing simplicity, customization, and concise communication helps employees clearly understand what benefits are available and how to use them. Straightforward benefits design combined with clear explanations enables employees to make informed decisions and increases the perceived value of the benefits package.

3. Transparency and Collaboration Strengthen Benefits Programs: Greater transparency is critical in navigating the complexity of the healthcare and benefits system, particularly for HR leaders responsible for evaluating and managing plans. Strong collaboration between vendors, brokers, and HR teams can help ensure benefits offerings align with workforce needs and organizational goals. Partnerships that emphasize communication, empathy, and clarity can build trust while improving the overall employee benefits experience.