Perhaps a stupid question, but why are the arbitrators approving these payouts? Conflict of interest? Corruption? Apathy? Ignorance? Hatred of insurance companies? I can actually see arguments for...
Perhaps a stupid question, but why are the arbitrators approving these payouts? Conflict of interest? Corruption? Apathy? Ignorance? Hatred of insurance companies?
I can actually see arguments for the assistant’s payout not necessarily being hard capped as a percentage of the surgeon’s simply because there’s always a chance the surgeon got screwed on the billing somehow, but I don’t understand how there isn’t a flag against “more than 2x what the surgeon got” or “more than $300/hr” or “more than 3x the average for an assistant on this class of procedure” or whatever else that would very easily catch only wildly large payouts and trigger some kind of review panel to presumably rein it in a bit.
I read the arbitrators wanted to earn more fees through volume by encouraging the providers to pursue arbitration instead of settling the bill more traditionally, and then reward them with more...
I read the arbitrators wanted to earn more fees through volume by encouraging the providers to pursue arbitration instead of settling the bill more traditionally, and then reward them with more favorable judgements while ignoring the exorbitant amounts.
Looks like there's going to be an 85% reduction in fees to dissuade it among some other changes.
Pretty astounding to think they would approve those kind of judgements for just $115 per case.
The last article I came across said the arguments submitted to the arbitration are sealed, so no one can do any analysis of what arguments are persuading the arbitrators. Some people they...
The last article I came across said the arguments submitted to the arbitration are sealed, so no one can do any analysis of what arguments are persuading the arbitrators. Some people they interviewed speculated the providers were writing about past very low payouts and claiming they needed to make up for all the historical squeeze with a bonus payment.
It takes a surgeon around three hours to remove a cancerous prostate gland. Most sit behind a console, using joysticks to control a surgical robot with tiny clamps, scissors and other tools on its four arms.
An assistant stands at the bedside to place the robot’s arms, suction out fluids, and swap instruments at the surgeon’s instruction.
For those services, the standard fee paid by most health insurers is 16 percent of the surgeon’s earnings. But across the country, assistants are sometimes earning up to 25 times what the doctor makes, according to data reviewed by The New York Times and interviews with officials who manage large health plans.
They do it by capitalizing on a law intended to protect patients from surprise billing by providers not in their insurance plan. Under the law, those providers can file for arbitration, where they are able to make a case for much higher payments than they could otherwise receive from health plans.
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Patients typically have no idea when their cases end up in arbitration, and they pay what they normally would for an in-network provider. But the high payouts may encourage more doctors (and surgical assistants) to stop taking insurance and use arbitration instead.
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Doctors’ groups argue that insurers often offer payments that are too low for physicians managing complex cases. Several have sued health plans that they say have not paid awards, which are binding under federal law.
Surgical assistant groups say that health plans often refuse to let them in their networks, leaving them with payments that can be unpredictable and low. Luis Aragon, chief executive of Illinois-based Surgikal Assistants, says he pursues arbitration when insurers offer little to no money, such as a health plan that sent $30 for a three-hour robotic surgery.
“If I could guarantee $400 per case, I’d be very happy with that,” he said. He typically asks for $850 to $1,500 in arbitration, and wins most cases.
But he said very large awards for assisting are signs of a system gone awry. “$100,000, $50,000, all these amounts are way out of line,” he said. “And that is not sustainable for health care costs.”
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Some in-network surgeons appear to team up often with the same out-of-network assistants. At Lenox Hill Hospital in Manhattan, Dr. Shari Reitzen-Bastidas frequently assists Dr. Nicholas Bastidas, her husband, on operations to make transgender women’s faces look more feminine.
She has repeatedly earned six to 224 times as much as him, according to records reviewed by The Times.
In one instance, arbitrators awarded Dr. Reitzen-Bastidas $210,000 for her work assisting with an operation that involved reshaping bones around the eyes. Dr. Bastidas earned $12,767 for the same case.
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A Wisconsin neurology practice received $196,215 for a 2024 spinal fusion operation — $125,058 to the main surgeon, Dr. Arvind Ahuja, and $70,707 to his assistant, according to documents reviewed by The Times. Typically, health plans would pay the surgeon $9,310 and the assistant $1,562. The practice split the operation into multiple bills, enabling them to bring 11 separate cases to arbitration, winning all of them.
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With little movement in Washington, health plans are experimenting with benefit cuts to lower arbitration payouts.
Owen Rumelt, a partner at the law firm Cary Kane, who advises union health plans, said many of his clients have begun canceling contracts with hospitals where out-of-network operations are common.
Perhaps a stupid question, but why are the arbitrators approving these payouts? Conflict of interest? Corruption? Apathy? Ignorance? Hatred of insurance companies?
I can actually see arguments for the assistant’s payout not necessarily being hard capped as a percentage of the surgeon’s simply because there’s always a chance the surgeon got screwed on the billing somehow, but I don’t understand how there isn’t a flag against “more than 2x what the surgeon got” or “more than $300/hr” or “more than 3x the average for an assistant on this class of procedure” or whatever else that would very easily catch only wildly large payouts and trigger some kind of review panel to presumably rein it in a bit.
I read the arbitrators wanted to earn more fees through volume by encouraging the providers to pursue arbitration instead of settling the bill more traditionally, and then reward them with more favorable judgements while ignoring the exorbitant amounts.
Looks like there's going to be an 85% reduction in fees to dissuade it among some other changes.
Pretty astounding to think they would approve those kind of judgements for just $115 per case.
The last article I came across said the arguments submitted to the arbitration are sealed, so no one can do any analysis of what arguments are persuading the arbitrators. Some people they interviewed speculated the providers were writing about past very low payouts and claiming they needed to make up for all the historical squeeze with a bonus payment.
From the article:
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