Tia Goss Sawhney is an actuary, a doctor of public health, and the owner and managing director of Teus Health. She has worked with the price transparency machine-readable files, inside the independent dispute resolution process itself, and with the federal IDR public use files, a combination that lets her interpret the arbitration system all the way down into the claims data.
The No Surprises Act has largely done its job for patients. This conversation focuses on the other half of the law: the independent dispute resolution process that decides what an out-of-network provider gets paid. Tia explains how the qualifying payment amount is set and why it starts too low, how elective surgeries at in-network facilities end up in arbitration, and how the professional fees on a single surgery can climb from tens of thousands of dollars to hundreds of thousands. Listeners walk away knowing how to spot probable IDR claims in their own data, how those awards reach employees through premiums and wages, and where employers might push back.
In this episode
- Why Tia believes commercial pricing only changes when self-funded employers demand it, and what the Consolidated Appropriations Act opened up
- Where the No Surprises Act is working for patients, and the one gap left for reference-based pricing plans
- Why the qualifying payment amount starts too low: 2019 rates, CPI trending, and ghost rates
- Providers winning more than 85% of determinations, and why no one but the arbitrator sees the justification
- How elective surgeries at in-network facilities land in IDR, from assistant surgeons to neuromonitoring
- The August amendments and the Fifth Circuit’s QPA decision, and what neither one changes
- Where challenges could come from: EmblemHealth’s suit against Dr. Norman Rowe, and False Claims Acts for public employers
- How to find probable IDR claims in your own claims data, and how the cost reaches employees
Figures cited in this episode
These numbers come from the federal IDR public use files, so here they are precisely, with the source.
The 2.2 million disputes Tia cites for 2025 matches the payment determinations that certified IDR entities made that year: 1,082,247 in the first half and 1,145,039 in the second.
Providers prevailed in about 88 percent of payment determinations in the first half of 2025 and about 85 percent in the second half, in line with Tia’s “more than 85 percent.” HaloMD was the top initiating party in both halves of the year.
The IDR amendments Tia mentions took effect August 3, 2026. As she notes on tape, aggregate data reflecting them is not expected until spring 2027.
The dispute volumes and win rates above are drawn from the CMS Federal IDR supplemental background for July 1 to December 31, 2025.
Transcript
Andrew Gordon: Welcome to The Price of Healthcare. I’m your host, Andrew Gordon. On this show, we sit down with the executives, influencers, and people working to build a functional healthcare market. Every episode, we’re unpacking what’s broken, what’s working, and what it takes to buy healthcare with informed choice. In this episode, we’re going to be discussing the No Surprises Act with a particular emphasis on the independent dispute resolution process embedded within the act. My guest today is Dr. Tia Goss Sawhney. Tia is the director, managing director, and owner of Teus Health, where she does analytic and public policy work. She’s a fellow of the Society of Actuaries and a member of the American Academy of Actuaries. She holds a doctorate in public health, and she teaches healthcare claims data analysis as an adjunct clinical associate professor at NYU’s School of Global Public Health. What compelled me to reach out to her is her expertise in healthcare payments and health insurance claims data, from the high-level policy perspective down to hands-on analysis of large datasets. She has worked directly with the price transparency machine-readable files within the independent dispute resolution process, and with the independent dispute resolution process public use files. This combination is rare and it is exactly what this topic needs. Tia, welcome.
Tia Goss Sawhney: Thank you, Andrew. I’m so delighted to be here and many thanks to you and to Payerset for inviting me.
Andrew Gordon: Happy to have you on board. So most of the media coverage treats the No Surprises Act as a consumer protection story. And on that count, it has largely been working. Far less attention goes to the half that decides what gets paid to the provider, or to the fact that the money behind it comes from self-funded employers who typically have no role in the negotiation. The law was built to do two things: keep patients out of the middle of a bill they never agreed to, and settle what the plan pays the out-of-network provider. That second piece runs through arbitration called the independent dispute resolution. Each side submits a number, an arbitrator picks one, and there’s no splitting the difference. Now, regulators expected about 22,000 of these cases a year. We’re covering the independent dispute resolution process and what’s been happening inside it, as well as how it has evolved since it started. So Tia, let’s set the stage a little bit. Tell me about your work and how you ended up working on out-of-network payment.
Tia Goss Sawhney: My first work after studying finance at the undergraduate level at Wharton 40 years ago was a, was as a health insurance actuarial trainee, which means I’m a data person through and through. And I cannot look at data without thinking of costs. So that makes me a money person. Although I have deep experience across commercial, Medicaid, Medicare insurance, much of my work since 2019 has been on behalf of self-funded employers, so specifically on the self-funded portion of commercial insurance. Commercial insurance has systematic structural issues and pricing irrationalities, which I believe will only change when self-funded employers demand change. Unfortunately, until the Consolidated Appropriations Act of 2021, the same act that includes the No Surprises Act, self-funded employers most often were not permitted to access their own payment data. But they can now. And once employers and unconflicted people working on their behalf open the data, problems jump out. I tell my colleagues it’s like fishing from a bucket. Exorbitant payments made as a result of the No Surprises Act truly jump. They are large, and they’re — and not all of them, but some of them are so large that they just stand out. In addition, I was until recently an executive at a prepayment firm where I worked on behalf of self-funded employers trying to get ahead of the IDR awards and build sounder cases. We were rarely successful, the truth be told.
Andrew Gordon: And so thinking about your multifaceted background, how do these various lenses land differently? I mean, comparing to other professionals, when you’re in this space, you’re examining the No Surprises Act, you’re looking at some of these things underneath it. Talk to us a little bit about how that comes together.
Tia Goss Sawhney: As I said, my work is always grounded in data. I’m always looking at the data. But over the decades of looking at the data, I’ve pulled in the law. I’ve pulled in clinical. I’ve been trained as a researcher, and I’m very committed to social justice and very repelled by fraud.
Andrew Gordon: Switching gears a little bit here, the report card. The No Surprises Act became effective January 1st, 2022. It’s almost five years old. How would you say we’re doing?
Tia Goss Sawhney: As you mentioned earlier, from a consumer protection point of view, I believe that the No Surprises Act is doing very well. Consumers are now no longer responsible for surprise bills, and that’s wonderful. That was an injustice against patients. The one ongoing area is with respect to reference-based pricing plans. Under reference-based pricing plans, which are a very small portion of the insurance market, emergency services are exempt from surprise billing, but other services are not. But that’s a feature of reference-based pricing plans. It’s not the fault of No Surprises Act. With respect to paying a fair amount, I would say that the system is failing. And we’re going to talk about more specific examples later on, but it’s failing in two regards, at the low end and at the top end. So on the low end, the starting price for a negotiation is supposed to be something called the QPA, the Qualified Payment Amount, which is supposed to be a market price, an estimate of a market price, a fair price. We’ll call it a fair price. And the law sets out a very specific methodology for calculating the QPA, and that is the median rate for that service as paid by that payer vis-à-vis negotiated rates in 2019. 2019, a very critical date, trended forward using the Consumer Price Index urban version to today, to the date the service was provided. Why is that a problem? That is a problem because in 2019, healthcare prices were not available.
Tia Goss Sawhney: They were closely guarded secrets. And it’s also a problem because healthcare costs have gone up faster than the CPI urban since 2019. And it’s also a problem because calculating the median negotiated rate, some payers don’t have enough of those rates for them to be truly meaningful for that particular service, or they have a lot of the rates, but they’re essentially ghost rates. They’re with providers who never actually provide the service because a provider who provides 100 of the services, a provider who provides one of that services, one of that type of service a year, and a provider who provides nothing is all weighted equally. So QPAs tend to be too low. So the starting price is too low. The flip side, though, is that providers and their vendors have been very effective at putting forth and winning arbitration awards that are much, much too high. And when I say too high, 10 times, 100 times any reasonable estimate of the market value, which is just stunning. And it’s a stunning waste of our system’s resources. This is particularly happening within elective surgeries. And I want to emphasize providers and their vendors. I’ve been digging through the data recently, and it’s really stunning. The market is controlled by a handful of vendors. For example, in 2025, there were 2.2 million disputes, and nearly half of those disputes were represented by just five vendors. In fact, the top vendor, HaloMD, accounted for more than 400,000 disputes.
Tia Goss Sawhney: HaloMD and presumably others get paid a percentage of the additional revenue that they bring to the out-of-network provider. Therefore, the higher the award they get, the more they get paid. And this is coming out of all of our pockets. It’s coming out of employers’ pockets. It’s coming out of the pockets of anyone who pays, who self-funds for insurance or who pays an insurance premium.
Andrew Gordon: Seems like there’s certainly a lot to unpack and dive into there. So I wanted to just round out in terms of the, the good and bad aspects, the successes and the failures relative to the NSA. You know, I’m hearing that from a consumer protection standpoint, from being able to reduce the responsibility that patients have toward balance bills and everything else of that nature, we are certainly doing really well. But then in terms of the points where we need some more emphasis is just understanding the incentives behind and how these rates and negotiations are essentially being handled and the methodology behind that, we need to unpack a bit better.
Tia Goss Sawhney: Yes, I agree.
Andrew Gordon: So going into the QPAs a bit more, you defined them for us and really appreciate stepping through how variable they could be. How exactly are these QPAs failing?
Tia Goss Sawhney: People don’t have confidence in them. And once people don’t have confidence, it becomes a free-for-all is how I would best summarize it. Instead, what’s being relied on more heavily is the provider offer and the payer’s offer. And with respect to the truly exorbitant awards, it is the provider’s offer that is being accepted. But overall, it’s important to emphasize that more than 85% of the time across all awards, big and small, it is the provider’s offer that’s being accepted. The system at the, at this moment is very statistically biased toward the providers.
Andrew Gordon: Fascinating. So QPAs are essentially the starting point for these negotiations and IDR awards. They’re generally low based on what’s happening on the backend as a solution. What’s coming out of it is a much higher basis. These exorbitant awards that you speak of, what’s the basis for these? Why is there such a large delta there?
Tia Goss Sawhney: I wish I could tell you, but here’s, here’s another catch to the, the IDR system. And that is the provider makes an offer, the payer makes an offer, and as you mentioned, as you said before, the arbitrator has to choose one. There’s no splitting the difference. The arbitrator then writes a report that says which one they chose. The offer made by the provider and the offer made by the payer are not disclosed. They’re not disclosed to each other, so therefore there’s no rebuttal. They’re not disclosed to the public. They aren’t reviewed under appeal because there is no appeal process. So anyone can write any justification, and the only entity that sees it is the independent dispute resolution entity. Presumably CMS has a right to look at it too, but there’s no formal process for triggering a formal review, a formal appeal or even a formal review. So I can’t tell you what’s being said that justifies these very large rewards.
Andrew Gordon: I also noticed too, Tia, as you were laying it out for us, it’s contrary to how a lot of negotiations happen where you have two parties that come to the table and they’re exchanging offers back and forth. They’re eventually settling on something. It seems like there’s a lot of mechanics or aspects of this that are much more controlled or confidential in fashion, or just are not privy to those key parties. And as we talked about with employers funding a good chunk of it as well, and not even really playing a massive role or any role in the negotiation, it starts to get really challenging. Can you talk a little bit about these? There’s examples of elective surgeries that are being arbitrated under the IDR, and just wanted to get some more clarity. Because when I think about the No Surprises Act, and we think about emergency care and balance billing, and we bucket all of that into our mind, and we think, well, these aren’t necessarily surprise cases or services, how exactly does it end up that these elective surgeries are being arbitrated under the IDR process?
Tia Goss Sawhney: I ask the same question. Under the IDR process, the professional charges for any procedure performed in an inpatient facility is subject to IDR, with one exception, and that is if the lead surgeon has the patient sign a form in advance that says whereby the patient acknowledges that they’re taking full responsibility. So if I was considering a breast reduction surgery and I go willingly and knowingly go to an out-of-network physician, then the physician could hand me the form and say, “Sign here and you take full responsibility.” Or the physician could not hand me the form, or the physician could hand me the form and I say, and I could say, “I’m not signing this. I don’t want to pay this bill.” Then if the surgery, if my elective breast reduction surgery is at an in-network facility, that physician who didn’t give me the form or who gave me the form and I didn’t sign it can then file for payment under IDR. I consider that to be a mistake, an unintended consequence, or something to be corrected in the current IDR rules. Because if the patient knowingly selects a provider who’s out-of-network, then that is not a surprise. The second scenario is, staying with breast reductions for the moment, the physician decides that they want an assistant surgeon in the operating room. Now, the patient has not selected the assistant surgeon, so one could argue that is a surprise. But here’s where it’s not as much of a surprise. What if the assistant surgeon is from from the same practice as the lead surgeon? Or what if the assistant surgeon is the buddy of the lead surgeon, but from another practice? Is that a surprise, or is that stuffing the operating room to maximize billings? I have seen cases, I’ve worked cases where, and I can see it in the data, where the assistant surgeon and lead surgeon are from the same practice.
Tia Goss Sawhney: The anesthesiologist — did the surgeon select the anesthesiologist, or is the in-network facility where the procedure is happening knowingly putting out-of-network anesthesiologists into their ORs? For an elective surgery, there should be no surprise about who’s in the operating room. It’s a summary of what I’m saying. Yet the surgeon, the assistant surgeon, and the anesthesiologist, and I mustn’t forget the neuromonitoring company, which is not an issue for breast reduction as much as for spinal surgeries, which are often elective too, are all coming into the IDR process.
Andrew Gordon: So in a lot of these cases, Tia, that you’re saying the facility itself typically would be in-network, and then these folks who are supporting providing the operation at the individual level, most of them are out of network, just so that I’m understanding it correctly?
Tia Goss Sawhney: Well, I mean, most surgeries, most days are all in network. But for IDR cases, where there’s one provider out of network, there’s often a whole cast of providers who are out of network. And they’re interconnected with each other. They’re from the same medical practice, or they otherwise have connections to each other. You will see the same anesthesiologist working with the same surgeons, the same neuromonitoring company. Sometimes a neuromonitoring company may be a sister group to the medical group.
Andrew Gordon: I see. Okay. And I guess that makes sense because they would be supporting each other for these services or these operations, and they probably end up working together in a variety of different aspects. But I guess, could you help us understand and break down from a lead surgeon versus an assistant surgeon standpoint versus some of these other characters, as you mentioned, how that plays into either exorbitant awards or this IDR process and what people are getting paid. Help us kind of understand why these different roles are important to segment.
Tia Goss Sawhney: Each of those out-of-network providers providing one or more services related to that surgery, if the surgery is in an in-network facility, can go through the IDR process. Therefore, a surgery that all the professionals combined may have been paid $20,000, $30,000, $40,000 can end up costing $500,000, $600,000, $700,000, $800,000. And I’ve actually been working this data for the last few months, and it’s astounding.
Andrew Gordon: Many multiples above, as you mentioned, what a typical reimbursement expectation would look like. You had mentioned before that there is little or no appeal processes or kind of accountability measures in place to prevent some of these exorbitant awards from happening. Talk to us a little bit about what’s there, what exists, what doesn’t exist.
Tia Goss Sawhney: Disclaimer here, I am not a lawyer. So any lawyer listening, please forgive me. The way the NSA was written, there was, it was written without any private right of action. So the IDR entity awards have the force of a government decision. They do not have private right of action. And this has been challenged in the courts multiple times. So at the moment, the only recourse is to go to a CMS website and write about your complaint. I shouldn’t use the word complaint because complaint, we think of complaints as something that gets filed in a lawsuit. It’s not that. It’s go to the CMS website and write about your gripe. You’ll probably never hear from CMS and they don’t have to do anything. They may do something over time if they get enough gripes about the same topic.
Andrew Gordon: Fascinating. So for the thinking about some of these modifications, going beyond just accountability or other processes that may or may not be present there, what would you say with the NSA IDR process being recently amended? What do you think with these changes that have become recently effective? Are they helping or hurting the process? What are you seeing?
Tia Goss Sawhney: We don’t see anything yet. The amendments to the process were effective in August, and it will be next March or April before data will — before aggregate data will come out. What the amendments did, though, was make the IDR process more accessible to providers. Cheaper, faster. It did not, in fact, address the issues that we’ve been talking about. In fact, one can reasonably expect it will mean that the number of IDR disputes will continue to grow.
Andrew Gordon: I did also just want to jump in and make a comment. Possibly also cycle over a question to you just relative to incentives and thinking about as these supportive clinicians and characters in these different services, as more of them either fall out of network or maintain out-of-network status, what incentive, given what we’ve talked about today with these exorbitant awards and the massive win rates that we’re seeing on the provider side, what incentive would these clinicians and folks have to maintain or work to be in-network with various insurance carriers?
Tia Goss Sawhney: Well, I firmly believe that most medical professionals want to be paid a reasonable amount for their work, that they want the payments to be fast, as fast and as frictionless as possible. To those professionals, thank you. There are, however, a subset of professionals, and more importantly, the medical groups that they work for who are into maximizing revenue. And if that is the game that the medical group is playing, then they should not be in a network. And if they can do their surgeries or procedures at an in-network facility, they then — they have lots of incentive to stay out of network and play the IDR game.
Andrew Gordon: So there was recently, just going back to as well the amendments and some of the latest things happening in the media and news relative to this process, there was a major court decision regarding qualified payment amounts. What do you see in terms of the results of that and the decision going back to helping or hurting, pros and cons, relative to where we’ve been and where we’re going?
Tia Goss Sawhney: The qualified payment amount decision was sound, but it was brought, the case was brought by providers in Texas. And so as such, it was to fix the problems that providers perceive with QPAs. Topping the list was the use of ghost rates. Ghost rate is when there are negotiated rates exist between a payer and a provider, but the expectations is that it’s never going to be used. So for example, an OB-GYN medical practice that in their contract with the provider has negotiated rates for heart surgery. The OB-GYN doctor’s never going to do heart surgery. But when the rates were negotiated, what they did is they created a rate set for all possible physician services. And the OB-GYN medical practice said, “Well, do the OB-GYN services seem to have good rates for us?” And they said yes, and they signed off on it. So their contract actually includes cardiac surgeries, but that’s a ghost rate, right? The other thing is that the decision said that the rates have to include incentive and bonus payments. So not all medical services are paid on a fee-for-service basis. Fee-for-service refers to when a specific service is rendered, there’s a specific rate for that service, and it’s paid. But there could also be payments associated with quality and bonuses so that the specific fee is paid for that service, but at the end of the year, if the doctor or the medical group has done a good job overall, they get an extra 20%. So to get rid of ghost rates and to include the bonus payments in the market rate calculation makes sense.
Tia Goss Sawhney: What it doesn’t — does not change, however, is that 2019 is the base. Most entities can’t verify the 2019 rates. Since 2022, rates have been public. So I can go today and look and see what Aetna is paying in a market for cardiac surgery services. And that’s available today. And it was available starting in 2022. There were problems early on with the files. The newer files are getting better, but we’re still stuck on 2019 and we’re under-trending.
Andrew Gordon: So we’re still stuck on 2019, and the idea is that we are going to have a lot more visibility and then accountability too with everybody being able to see the rates as of 2022 and the transparency and coverage files being released. That is really where we could start to see a little bit more of the rubber meet the road, if I’m hearing you correctly?
Tia Goss Sawhney: Well, and I wouldn’t use the 2022 files either. I would, you know, if I was creating the rule today, I would be using today’s files. So.
Andrew Gordon: For sure. Makes a lot of sense. I want to look into the future a little bit and just thinking about where change is going to come from, where the evolution of this is going to continue to go. We talked about with no appeal process and just challenging these individual exorbitant awards, how might people challenge these kind of moving forward? Talked a little bit about how folks historically have or have not been able to challenge them. What are we looking at when it comes to the system change here?
Tia Goss Sawhney: First and foremost, let me say again, not a lawyer. We need system change. The people paying these bills, which is largely employers, and among employers, it’s largely self-funded employers, need to understand what’s happening, and they need to bring forth change. In my mind, I believe, I hope, pray that there are opportunities for them to do so. So there is no private right of action against an IDR award. But are there other possibilities? Perhaps. But certainly one can make political noise, and I really advocate for that. And of course, political noise is most effective when employers and other organizations band together. So employer groups and coalitions need to be on top of this. I believe that there may be other opportunities also. So if you can’t take action against the award, can you take action against the provider or the vendor? Either one, because these exorbitant awards are not justifiable, but they put forth a justification. So how to break the veil of secrecy and get those justifications? And then if they’re making false statements within the justifications, that is a problem.
Tia Goss Sawhney: And at which point there is action that can be taken. So is there enough circumstantial evidence to cause, to break the veil of secrecy on the justifications and see what’s being written and challenge what’s been written? For example, there’s a case right now that Emblem Health has against Dr. Norman Rowe, who does breast reductions. He and his multiple provider groups do breast reduction surgeries primarily in New York and New Jersey and Florida. And Emblem Health has filed a case against him on just these grounds. Another way of going at it is for self-funded employers, states can’t regulate self-funded employers. So, but states can and do regulate providers. So are the providers following state law? So for example, New Jersey has a version of the federal Stark Law that it’s much more powerful than the federal Stark Law. And according to my read, not a lawyer, providers cannot self-refer. So a New Jersey surgeon who puts an assistant surgeon from the same practice in the operating room, that may be illegal — not a lawyer. Also in New Jersey, New Jersey has an NSA-type law, No Surprises Act-type law, that predates the federal No Surprises Act. And that seemingly prevents surgeons, the lead surgeons who provide an elective service from seeking payment in excess of the payer’s normal out-of-network payment. So if the patient selected the lead surgeon, their lead surgeon can’t under New Jersey law, according to my reading.
Tia Goss Sawhney: So could those payments be challenged under New Jersey law?
Andrew Gordon: You see a lot of these, Tia, as opportunities for employers to challenge it? Just want to make sure that I’m receiving that right and that is there anything else that you would say that employers might be able to do as it comes to and realizing how much of these awards they’re funding?
Tia Goss Sawhney: Well, if you look at the commercial market, the commercial market is dominated by employers. Now, it’s not — the employers often have insurance companies as their administrators. So when Emblem brings a suit against Norman Rowe, the actual cases that are described in the suit are actually cases where this surgery was provided to employees in dependence of New York City, New York City’s benefit plan. So, which brings me to another point. Public-funded employers are a special class. So false claims made against public employers, whether they’re state or federal, subject to — if it’s a federal employer, subject to federal False Claims Acts. And many states have an equivalent at the state level. So when you — they have state-level False Claims Acts. So when — to the extent that these awards are being made against public employers, they have the power of the, of the federal or state and/or state False Claims Acts. They also have potentially the power of the state-level judiciary and legal system. They have the power of the state attorney general.
Andrew Gordon: I was going to say, is there anything that I neglected to ask you that you’d like to share with the audience? I feel like we’ve had a really great conversation thinking about what’s happening right now, understanding where do we stand, what’s been the evolution to date, where it’s kind of been breaking, what are some ways and changes that are coming down the pipe, as well as just some changes that could help to make things operate a little bit more smoother with more accountability and transparency. Anything else that you wanted to add for the audience today?
Tia Goss Sawhney: I would encourage every employer, not just self-funded employers, to find out exactly what they have been paying with respect to NSA IDR claims. If you don’t know, you need to know. And self-funded is coming directly from your bank account. But if you are any employer over 50 employees, in some states 100 employees, then you’re experience-rated and these exorbitant awards are going into your experience rating. So therefore, ignorance is expensive. Go find out what you’re paying and then work toward change. Make political noise with politicians, with the press, via lawsuits, and work together, work with associations and coalitions, propose legislative change, demand transparency. Demand and appeal the process.
Andrew Gordon: So I wanted to actually dive in a little bit on your comment about looking at the claims, figuring out and understanding where this is happening. Could you add a little bit of color as to, I assume there’s not some massive sign that says this is an NSA IDR determination or what have you when going through the claims data. So could you help us understand how that might emerge or how that would become clear to an employer that is doing exactly that? They’re diving into their claims data, they’re looking through the information. What are they looking for as it relates to these specific things?
Tia Goss Sawhney: So just excuse me when I get a little technical here. There are, there are multiple paths to find the IDR claims, or at least the probable IDR claims. Keep in mind, IDR gets initiated after an initial payment. So what you’re looking for is a claim that was paid at a reasonable amount that two to six months later typically is paid at a much larger amount. And the way it works is the claim is paid, and then in the data you’ll see that the claim — the payment was reversed, and then a much bigger payment was made. Now, when claims are reversed and the much bigger payment’s made, there is hopefully a reason code, and hopefully one of the reason codes is IDR decision. That’s the best-case scenario. Unfortunately, the data that’s often distributed doesn’t include reason codes. So if your data doesn’t have reason codes, you’re still looking for that pattern. Was there a claim paid that several months later was repaid at a much, much larger amount? And that is a clue to probable IDR.
Andrew Gordon: With these claim adjustment reason codes and the possibility that those codes are there, but you said that sometimes they’re not. I don’t want to open too much of a can of worms, but I am curious, why might the data streams that folks are reviewing or having access to not be able to include these reason codes? And is it that sometimes they’re just not included in it? Is it that these codes are oftentimes there, they’re just behind the scenes and not commonly shared in the feed that goes to whether it’s employers or the folks who are reviewing these claims on behalf of employers? How would you explain and share that?
Tia Goss Sawhney: The codes are definitely there in the claims administrator system, which is often an insurance company’s system. But yes, it’s not distributed out because remember, historically, claims data wasn’t shared with employers. And now that it’s being shared, the exact fields that get shared are a matter of negotiation. And maybe no one — and so the reason codes have not been part of the request or part of what’s been distributed. But they are available. They can be produced.
Andrew Gordon: I see. And so just also to recap for the audience and to make a clarification. These exorbitant awards, when they’re being paid, there is no added expense to the member, to the patient, when these determinations and these claim adjustment reason codes are put in to say, well, the clinician was paid $5,000, six months down the pipe, that’s changed to $50,000. My out-of-pocket as a patient on that specific service is not going to waver. Is that correct?
Tia Goss Sawhney: It will. I mean, it could actually benefit the patient because if it was originally paid as an out-of-network claim, remember, initially it could have been paid one of two ways. It could have been paid as an out-of-network claim adjudicated at the in-network level, but at which point it’s not going to — it’s probably not going to change, but initially it could have been adjudicated or alternatively, it could have been adjudicated as an out-of-network claim at an out-of-network level. So in that case, then the patient could actually benefit. And you might say, but wait, why would — given the NSA, why wouldn’t the payer have adjudicated it upfront at the in-network level? The other thing that has been found and documented is that claims have gone into IDR, a substantial percentage, in fact, of the IDR claims that go into IDR and have awards are, in fact, claims that should never have gone in. So the payer may have adjudicated quite appropriately as an out-of-network claim, but it went into IDR, and the IDR entity decided that IDR applied, at which point it has to be readjudicated as an in-network claim.
Andrew Gordon: So there wouldn’t be a situation, or at least it wouldn’t be common to have a situation then where, from a patient cost-sharing perspective, they’re actually going to be expected to pay more, or they would be impacted in a negative manner?
Tia Goss Sawhney: No, it would, it would not be. Overall, patients are being well protected, but payers are not being well protected.
Andrew Gordon: The reason why I’m asking these questions to you is, as we’re familiar with the, the cases against Wells Fargo and Johnson & Johnson, and just some of these other major companies, that was originally brought a lot of the times by employees for exorbitant amounts of money paid or not being able to get competitive rates for certain things. I mean, as we talk about fiduciary liability, and for the audience who may or may not be familiar with the Consolidated Appropriations Act originally in 2021 and has since been going through a lot of updates as well to strengthen it, it’s very important for people, the employers who are funding and providing for and looking over and offering competitive benefits to their people to make sure that they’re getting the best rates possible and to make sure that they’re really targeting and finding value in those contracts and in the partnerships and the claims that they’re paying. How does the IDR process impact that when we talk about fiduciary responsibility? And then you have these exorbitant awards that they’re paying. Granted, a lot of it is not hurting the patient necessarily, as we said. But when you think about the high expense of healthcare and the damage to salaries or benefits because of this larger and larger expense growing on the employer’s accounting book, how do you kind of justify or where does or does not fiduciary liability play a role in this conversation?
Tia Goss Sawhney: Once again, I’m not a lawyer and the courts have been working on this. I would argue that it’s a very important part of fiduciary responsibility. Let’s look at it from a few perspectives. First of all, a lot of times employee contributions, employee premiums for their benefits are pegged at a percentage of the expected costs. If it’s 20% of the expected total cost, then every dollar extra that’s being paid is being paid — 20 cents of that is being paid by employees in their employee premiums. So even if the employee is being protected vis-à-vis their cost sharing, they’re paying for it in their premiums. Second of all, total cost of care affects what employers can pay in wages. It also affects whether an employer can even offer a plan. So, I mean, do we want to be paying 3/4 of a million dollars for all the professionals who attended a surgery where they reasonably collectively should have been paid under $50,000? That’s so $700,000 spread. If the employer’s paying that, that’s more employees that employer could hire. That’s more raises that employer could give. And sudden spikes in healthcare benefit costs, which a lot of employers are experiencing right now, may determine whether they even continue to offer a plan or whether they change the cost sharing on the plan or whether they up the percentage of the plan costs that the employee has to pay for premiums. I mean, ultimately, you know, employees pay.
Andrew Gordon: Bringing this home for us, talking about how we’ve seen cases grow year over year, we’ve seen these awards be dozens or hundreds of times higher than fair market rates for services, thinking about what’s coming down the chain, anything else that you want to share as we round this out in terms of what people should be aware of, and what their action items should be, specifically for, sounds like, employers and policymakers and also a few other stakeholders?
Tia Goss Sawhney: My very short summary is get involved. Look at the data, get involved, ask questions, challenge. There are many other topics I could talk about, including more details of IDR, so I hope you will invite me back for further discussions.
Andrew Gordon: For sure. Absolutely. It’s been a really good conversation. Now, for those in the audience who are interested in reaching out to you to continue the conversation privately, where would you direct them?
Tia Goss Sawhney: Um, reach out to me by email. My email address is T-G, as in Tia Goss, Sawhney, S-A-W-H-N-E-Y, at teushealth.com.
Andrew Gordon: Excellent. Tia, thanks so much for coming on today. It was a pleasure having you.
Tia Goss Sawhney: Thank you, Andrew. My pleasure.
Andrew Gordon: That’s a wrap for this episode of The Price of Healthcare. We appreciate you tuning in, and we’ll see you on the next one.