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To save U.S. health care, stop abusive hospital billing

The Washington Times

OPINION:

Health care costs in the United States are rising fast, and families are paying the price. A large and often overlooked factor driving up premiums and out-of-pocket costs for American consumers is abusive billing by hospitals.

If we are serious about Americans’ well-being and their wallets, then it’s time decision-makers turn their attention to these dishonest practices.

In 2024, national health care spending increased by 7.2% to $5.3 trillion, or $15,474 per person. Health care spending now accounts for 18% of the U.S. economy, and it is expected to grow faster than gross domestic product in the next decade.

Workers and small businesses face higher insurance premiums and larger deductibles. Out-of-pocket spending alone reached $556.6 billion in 2024, growing nearly 6% in a single year. Even insured families increasingly delay care or take on medical debt as costs rise.

Hospitals are not just one contributor among many. They are the dominant driver of recent spending growth. A brand new analysis found that hospital spending accounted for $277 billion, or 40%, of the entire increase in national health care spending from 2022 to 2024, far more than any other category of care.

In 2024, hospital spending reached $1.63 trillion, nearly one-third of all U.S. health care expenditures, and grew 8.9% in a single year. That growth outpaced overall health care spending and translated directly into higher prices paid by private insurers, Medicare, Medicaid and patients themselves.

The problem is not simply how much care hospitals deliver but also how they bill for it. Sometimes, there are billing errors, but other times, it’s undeniably fraudulent.

Common practices include billing for services patients never received, charging twice for the same test or procedure and adding facility fees that inflate prices just because outpatient care occurred in a hospital-owned setting. Research has documented that “consumers often directly bear the brunt of these charges.”

Upcoding is one of the clearest examples of how billing behavior inflates costs. A peer-reviewed study examining hospital discharge data found that from 2011 to 2019, the number of hospital stays coded at the highest severity level increased by 41%.

After adjusting for patient health, length of stay, and hospital characteristics, researchers “estimated that the increase would have been 13% in the absence of changes in coding behavior.”

The financial impact is substantial. Upcoding was associated with $14.6 billion in additional hospital payments, including $5.8 billion from private health care plans, $4.6 billion from Medicare and $1.8 billion from Medicaid. These are dollars ultimately paid through higher premiums, higher taxes and higher out-of-pocket costs.

One analysis found that technologies enabled by artificial intelligence reportedly use ambient listening to capture clinical interactions and analyze lab reports and physician notes and then assign billing codes that don’t accurately reflect the care given.

Where this technology was used, researchers often observed sharp spikes in the number of patients coded with conditions far more complex than the care they received, resulting in millions of dollars in improper and inflated charges.

To make matters worse, independent physicians’ practices are being bought up like crazy by big hospital systems. Health care economists determined, “These acquisitions led to an average price increase of 14.1% for the acquired physicians.”

This paradigm can even result in hospitals billing extra “facility fees” on top of professional charges. These are ostensibly overhead charges but do not necessarily cover costs specific to the setting or the patient being billed.

The consequences are predictable. Higher hospital billing leads to higher costs for Medicare and Medicaid, employers and families. Medical debt rises and affordability worsens, even as total spending continues to climb.

Legislators and regulators must curb abusive hospital billing practices. For the sake of taxpayers, employers and patients, hospital billing integrity has to be treated as an urgent cost control imperative, not a technical footnote.

Regulators should strengthen oversight. Congress should accelerate site-neutral payment reforms and limit excessive facility fees. At the very least, decision-makers shouldn’t undermine the tools that both public and private payers deploy to ensure billing accuracy or the penalties they impose to discourage repeat overbilling.

Hospital billing must be transparent, accurate and accountable before the bill reaches a kitchen table. Patients should not need forensic accounting skills to avoid being overcharged.

With hospitals accounting for the lion’s share of health care spending, and that cost rising by hundreds of billions of dollars every year, abusive billing is not a side issue. It is a core driver of America’s health care affordability crisis.

• Jason Altmire is an adjunct professor at the Texas Tech University Health Sciences Center. He has been an executive in the hospital and health insurance industries. He served three terms in the U.S. House of Representatives.

Five Hospital Billing Scams That Can Cost You Thousands

Center for Medicine in the Public Interest

You go to the hospital to get better — not to get financially blindsided. Yet every year, millions of Americans open their mailboxes to find medical bills that make them gasp: $8,000 for a few hours in the ER. $3,500 for lab work. Thousands more for doctors they never met.

Hospital billing in America has become so complex that even experienced healthcare professionals struggle to decode it. Hidden in that complexity are practices that can quietly cost patients thousands of dollars — often without them realizing they’ve been overcharged.

Here are five hospital billing traps you need to know about — and the simple questions that can protect your wallet.

1. Upcoding: When a Routine Visit Becomes “Critical Care”

One of the most common billing abuses is known as upcoding — charging for a more serious and expensive level of care than was actually provided. For example, a relatively straightforward emergency room visit for a minor injury or shortness of breath may be billed as “critical care,” dramatically increasing the charge. The difference between billing codes can mean hundreds or even thousands of dollars.

Hospitals bill insurers — and patients — using CPT (Current Procedural Terminology) codes that determine how much gets paid. If the code reflects a higher level of complexity than your visit warranted, you pay more.

Question to ask:

Can I get an itemized bill with CPT codes?

Once you have those codes, you can compare them to your medical record — and dispute anything that doesn’t line up.

2. Surprise Out-of-Network Charges — Inside an In-Network Hospital

You did everything right. You chose an in-network hospital. You checked with your insurance company. You confirmed coverage.

And you still get billed.

Even when a hospital is in-network, certain providers inside the hospital may not be — anesthesiologists, radiologists, emergency room physicians, pathologists. You don’t choose these doctors. You may never even see them. But you can still be billed at out-of-network rates. While federal law has reduced some forms of “surprise billing,” gaps and gray areas remain, particularly for ground ambulances and certain specialty services.

Question to ask (before a scheduled procedure):

Will all providers involved in my care be in-network?
If the hospital can’t answer clearly, push for specifics — in writing.

3. Duplicate or Phantom Charges

Hospital bills are long, dense, and often nearly impossible to decipher. That’s partly why duplicate or phantom charges slip through.

Watch out for duplicate charges and bills:

The same lab test billed twice
Charges for medications you never received
Supplies you didn’t use
Procedures that were canceled but still billed
Sometimes these are honest clerical errors. Sometimes they are the byproduct of fragmented hospital billing systems. Either way, patients pay if they don’t catch them. Studies consistently show that a significant percentage of hospital bills contain errors --
and those errors often favor the hospital.

Question to ask:

Can you show me where this treatment is documented in my medical record?
If it’s not documented, it shouldn’t be billed.

The No Surprises Act Is Raising Costs

The Well News

When we visit a doctor or hospital, we look to see whether they’re “in-network” or “out-of-network.” Why? We do it because we know we will probably pay more if we choose to receive out-of-network care.

In-network providers have contracts with health plans and have agreed to set rates — amounts typically set between what Medicare pays for a service and what’s considered reasonable and competitive for the local market. Patients know what to expect when they see the bill: a copay, a deductible and an amount that won’t bankrupt them.

Out-of-network providers haven’t signed those contracts and may expect to be paid their billed charges. Patients pay more out-of-pocket when they choose to see one.

The key word here is “choose.”

What happens when a patient doesn’t choose to see an out-of-network doc?

Prior to 2022, in an emergency or when a patient thought they were receiving routine care at an in-network hospital, and in-network rules applied, they sometimes got hit with massive surprise bills — on occasion, for tens of thousands of dollars. A patient might choose an in-network facility for a surgery, only to discover the anesthesiologist was out-of-network. The bill would land in their lap.

Congress tried to fix this. The No Surprises Act, implemented in 2022, protects patients with private health insurance from these types of unexpected financial blows, and as a physician, I support it.

Under this law, out-of-network providers can no longer balance-bill the patient in emergencies and other situations, like interpreting an x-ray or giving anesthesia at an in-network hospital.

Under the law, the provider must bill the health plan and if they don’t agree with the payment, they have 30 days to try to negotiate with the plan for more money. If they reach no agreement, the federal government has created the Independent Dispute Resolution process, where an independent third-party arbitrator becomes involved and decides in favor of either the amount requested by the doctor or the amount offered by the plan.

This is where things appear to have gone wrong.

There is no further negotiation.

There is no compromise.

The arbitrator doesn’t tell the doctor they’ve requested too much or the plan that they are offering too little. There are no outer bounds. The arbitrator chooses either the higher or lower amount.

Researchers have reported significant cost variability and a lack of transparency in third-party arbitrator decisions.

Most decisions are for the higher amount requested by the physician. Insurers have been vocal about arbitration entities awarding excessive payments for many claims that shouldn’t even be eligible for payment under the system because they don’t qualify for consideration.

The volume of IDR cases in 2025 was already 40% above 2024. Since providers win more than 85% of the time, often receiving awards three and four times higher than in-network rates, it’s no wonder that certain groups are flooding those arbitration entities that have frequently ruled in their favor with all their out-of-network claims.

This is driving even more awards, and now these additional costs have begun to impact employer-funded health plans, meaning that American workers and families will foot the bill through higher premiums and reduced benefits.

Most physicians don’t participate in this behavior. In fact, most doctors accept in-network contracts, charge reasonable rates and treat patients, not the system.

A small minority of providers, though — most backed by private equity and sophisticated billing operations — are exploiting the IDR process created by the law, driving massive costs into American health care.

Critics argue that insurers underpay out-of-network doctors. The math doesn’t support this. One study found the median price of surgeries jumped from $1,232 for in-network to an average settlement of $14,220. Similarly, imaging procedures jumped from a $608 in-network price to $3,337 in arbitration.

These outlier bills don’t hurt insurance companies. They hurt real people.

Reforming the IDR doesn’t mean shortchanging honest doctors. It means closing a loophole that a few bad actors are exploiting.

The law was designed to settle certain out-of-network billing disputes — not to serve as a high-priced auction for routine procedures.

It’s always easy to blame it on the insurer, but when a surgery price jumps 10 times, repeatedly, not because of medical necessity, but because of billing strategy — something has gone very wrong.

We need policy adjustments to the IDR process that maintain all the patient protections of the No Surprises Act and create fairer and more predictable payment benchmarks for all parties involved.

Andrea Gelzer, MD, is CEO of Qual-IT Strategies and a physician-executive with deep payer industry expertise, board leadership experience, and recognized thought leadership in health information technology, value-based care, and health care innovation. She can be found on LinkedIn.

Private Equity Hijacked a Patient Protection Law

RealClearHealth

President Trump did what Washington had failed to do for decades: he stood up for patients and put an end to one of the most abusive practices in American healthcare. Surprise medical billing, where families did everything right and still got crushed with massive, out-of-network bills, was a massive scam hiding in plain sight. The No Surprises Act was meant to shut it down, and under President Trump’s leadership, it did exactly that.

Patients are no longer being ambushed with potentially life-shattering bills after emergency care. That is a real achievement.

But passing strong, pro-patient reform is only half the battle in Washington. The other half is stopping entrenched interests from figuring out how to exploit it. And once again, private equity firms – perpetually flush with cash, lawyers, and lobbyists – have found a way to game the system.

While surprise bills may be down, healthcare costs are not. In fact, the No Surprises Act has quietly triggered about $5 billion in new costs in just its first three years. Those costs will be passed on to working Americans through higher premiums and employer costs while wages stay stagnant.

So how did a commonsense patient protection turn into a profit engine for private equity?

The answer lies in a last-minute arbitration scheme buried inside the law: an “Independent Dispute Resolution” (IDR) process that was aggressively pushed by provider groups and backed by private equity money. The IDR process was originally intended to serve as a narrow, last-resort arbitration mechanism to fairly resolve occasional payment disagreements between insurers and providers, without involving patients or driving up overall healthcare costs. But what was sold as a narrow backstop has instead become a weapon.

For years before the law, private equity firms had already turned emergency medicine into a gold mine. They bought up physician staffing companies in areas where patients have no choice and no leverage: emergency rooms, radiology, anesthesiology, and air ambulances. No one price-shops when they’re rushed to the ER. Private equity understood that and built a business model around it.

When surprise billing was finally shut down, those firms didn’t walk away. They simply adapted.

Through the IDR arbitration system, private equity-backed providers now flood the federal process with disputes, far beyond anything regulators anticipated. Instead of the roughly 17,000 cases per year the government expected, nearly 200,000 disputes were filed in just nine months after the system opened.

A small handful of private equity-owned companies dominate these filings. Two firms alone account for more than 40 percent of resolved claims in recent years. And they’re winning about 85 percent of the time.

When they win, they don’t just get paid. They secure reimbursements three to four times higher than normal in-network rates. That money doesn’t come out of thin air. It comes out of the healthcare system, and ultimately, out of the pockets of workers and employers.

Even more troubling, private equity isn’t just profiting on the provider side. Several companies hired by the federal government to act as certified arbitrators are themselves backed by private equity firms. In some cases, those same investment firms also own healthcare providers filing disputes into the system. That’s not a free market. That’s insiders playing both sides of the table. It is completely insane.

President Trump has spent his career calling out this exact caliber of elite abuse. Powerful financial interests are exploiting complexity and hiding behind bureaucracy to shift costs onto ordinary Americans while claiming to act in the public interest.

The No Surprises Act was the right reform. It protected patients just as it was supposed to. But private equity found the loopholes and exploited them to the maximum.

Now the job is to finish what President Trump started: tighten the arbitration process, shut down abusive filings, expose conflicts of interest, and stop Wall Street firms from using healthcare as a cash-extraction scheme.

Protect patients. Lower costs. Drain the healthcare swamp.

Author: Stefano Forte, January 21, 2026.

Stefano Forte is the President of the New York Young Republican Club and Executive Director of the 1776 Project PAC

How Congress Should Keep Fighting Surprise Medical Bills

Third Way

Imagine going to the emergency room thinking your insurance would cover the visit, only to get hit weeks later with a bill from an out-of-network doctor you never met and didn’t choose. That used to be the norm. Even when patients did everything right—having coverage and going to an in-network hospital—they could still end up on the hook for thousands of dollars in surprise bills. Stories like this were the lived experience of millions of Americans before the No Surprises Act’s passage, driving medical debt and forcing difficult choices between paying for care and meeting other essential needs.

Before Congress stepped in, nearly one-in-five emergency room visits and up to 70% of air ambulance rides resulted in surprise medical bills.1 The practice wasn’t just unfair to patients, it was predatory. Patients had no ability to choose the providers who would administer care for them (often in life-or-death situations), no warning that a bill was coming, and no leverage to negotiate after the fact. This meant that even insured individuals—those who had done everything ‘right’ in the health care system—could be hit with life-altering bills through no fault of their own.

The No Surprises Act protected patients from most surprise medical bills, but problems still persist. Instead of ending surprise medical bills across the board, Congress created a flawed and easily abused Independent Dispute Resolution arbitration process that risks shifting the burden of out-of-pocket costs in a way that increased patient’s premiums and did nothing to protect against surprise bills from ground ambulances. This report looks at how the law works, where it’s falling short, and what policymakers should do next to close loopholes and strengthen protections.

This report is part of a series called Fixing America’s Broken Hospitals, which seeks to explore and modernize a foundation of our health care system. A raft of structural issues, including lack of competition, misaligned incentives, and outdated safety net policies, have led to unsustainable practices. The result is too many instances of hospitals charging unchecked prices, using questionable billing and aggressive debt collection practices, abusing public programs, and failing to identify and serve community needs. Our work will shed light on issues facing hospitals and advance proposals so they can have a financially and socially sustainable future.

Overview of the No Surprises Act

In 2020, Congress passed the No Surprises Act, a landmark law to shield patients from the financial harm of surprise medical bills. Prior to the law, patients frequently received unexpected—and often massive—bills after receiving care at hospitals or clinics where some of the providers involved were not in their insurance network. These bills often came as a shock to patients who had no control over which anesthesiologist, radiologist, or emergency physician treated them.

A staggering 20% of hospital admissions at the time included a surprise medical bill, sometimes totaling tens of thousands of dollars.2 For example, a 44-year-old teacher in Austin, Texas was hit with a $109,000 bill after a heart attack resulted in a four-day hospital stay—all because some of her care was delivered by out-of-network providers.3

The core aim of the No Surprises Act is to protect patients from these unfair charges. The law bans surprise medical bills in three key situations:

1. Emergency services

2. Nonemergency services performed by certain out-of-network providers at in-network facilities

3. Air ambulance services

It requires insurers to cover emergency care without prior authorization and at in-network cost-sharing rates, regardless of the provider’s network status. This helps reduce financial burden on patients seeking lifesaving care who may not be in the right condition to ask questions about coverage for the services they are receiving.

For nonemergency situations, like when a patient has surgery at an in-network hospital but unknowingly receives services from an out-of-network provider (such as a surgeon or anesthesiologist), the law prohibits providers from billing patients more than the in-network cost-sharing amount. These protections have significantly reduced the risk of financial devastation from unexpected bills for millions of Americans with private insurance.

To address how providers and insurers settle payment disputes in these scenarios, the law also established a process known as independent dispute resolution, or arbitration. Rather than leaving patients caught in the middle between providers and their insurance, the dispute resolution process allows either the provider or the insurer to initiate a 30-day open negotiation to determine a fair payment. If no agreement is reached during that window, the dispute proceeds to arbitration, where a third-party arbiter selects one party’s proposed payment based on a range of factors.

While intended as a fair and balanced system, arbitration has instead become a high-volume, high-stakes arena—often leveraged by well-funded provider groups to secure rates well above typical in-network levels. As a result, the arbitration process has increasingly become a flashpoint in implementation, with some providers aggressively using arbitration to push for higher payments—which risks driving up premiums and administrative costs.

In the courts, some health care providers are also seeking to undermine the No Surprises Act through lawsuits against the federal government. For example, the Texas Medical Association has sued the federal government four times. In these suits, district-level courts ruled in favor of providers, which made the dispute resolution process more friendly to providers instead of patients.4 The American Hospital Association and the American Medical Association have also sued the federal government to undermine the law and give more preference to providers.

The Problem: Gaps in the Law are Keeping Costs High

While the No Surprises Act rightly protects patients from surprise bills, the law has failed to protect consumers from high costs in two key areas:

1. Excessive provider prices for out-of-network charges.

The heart of the No Surprise Act is an independent dispute resolution process. It was designed to resolve conflicts between providers and health plans over the price of an out-of-network service. The expectation at the time of the law’s passage was that most disputes would be settled during the initial 30-day negotiation window through good-faith negotiations, with only a limited number escalating to arbitration. Instead, the opposite is occurring.5

From the first year of implementation, CMS data revealed that arbitration was being used at volumes far beyond projections. In 2023 alone, over 657,000 disputes were submitted—more than 14 times the initial federal estimate.6 This increased to 586,000 in just the first half of 2024.7 Many of these filings came from a relatively small number of well-resourced provider groups, often owned or represented by large private equity-backed firms.8 One company, HaloMD increased its filings by 600% over two years.9 These corporate providers have developed a deliberate strategy of submitting disputes in bulk, which overwhelms the system and creates pressure on insurers to settle at higher payment amounts rather than incur the costs of prolonged arbitration. In addition, many filings are not eligible in the first place, which also floods the system.10

Further, arbitrators are permitted to consider factors beyond the median in-network rate, such as inflated historical out-of-network charges. This can skew awards toward the higher end of the payment spectrum, even in markets where negotiated in-network rates are much lower. In effect, the process allows providers to secure payments that exceed market norms, which insurers then factor into premium setting for employers and individuals. In 2024, the median prevailing offer when providers won was 445% of the median in-network rate.

Higher out-of-network arbitration awards are likely increasing the overall cost of care and rising premiums for employers—all of which ultimately erodes the affordability gains that the No Surprises Act was meant to achieve. If left unaddressed, the arbitration system risks becoming a permanent cost escalator—one that benefits high-charging providers at the expense of patients and payers alike.

2. Ambulance services.

The No Surprises Act also failed to end surprise medical billing for ground ambulances, even though they are used in 98% of emergency transportation methods.11 Up to 85% of ground ambulance claims are out-of-network, exposing patients to surprise medical bills in emergency situations.12 Despite ground ambulance services being the far more common option in emergency situations, these services continue to operate largely outside the consumer protections in the No Surprises Act, unlike less frequently used air ambulances.

However, the law did establish the Ground Ambulance and Patient Billing Advisory Committee, which developed a report to Congress on how to best solve this problem.13 In the Committee’s report, a number of recommendations were made:

1. Include ground ambulance emergency services under essential health benefit emergency services definition of the Affordable Care Act;

2. Limit patient cost-sharing to $100 or 10% of the rate of care, whichever is lower; and

3. Cap out-of-network ground ambulance prices at a percentage of Medicare determined by Congress if no state, local, or plan-provider contract rate is set.

To date, 18 states have protections against surprise medical billing for ground ambulances.14 In 2024, four states (Indiana, Mississippi, Oklahoma, and Washington) passed laws protecting consumers against surprise billing for ground ambulances, setting rates at a percentage of Medicare.15

How Has Congress Tried to Fix the Problems?

In 2019, the House Committees on Energy & Commerce, Ways and Means, and Education & Labor (now Education & the Workforce) held hearings and markups on surprise medical billing and proposals to end it. Further, the health care related committees in Congress passed competing proposals over how to address surprise medical billing.

In bicameral, bipartisan negotiations, House Energy & Commerce and Senate HELP came to an agreement that would have required health plans to pay out-of-network providers the median in-network rate within the region. This would have ensured providers would be paid what they commonly would if they were in network, while ensuring patients are protected against excessive costs.16 A similar version of this proposal was passed by Education & Labor.

However, right before the legislation was included in the 2019 end-of-year package, a rival bill was introduced that derailed the agreement.17 Supported by hospital and physician groups, this bill favored a heavier reliance on arbitration and provider-friendly processes. As a result, the limits on surprise medical billing were delayed by a whole year, not passing until 2020, and ultimately reflected the provider-backed reforms as opposed to the proposal putting patients first.

The initial debate surrounding surprise medical billing lacked an acknowledgement that the providers choosing to send patients these bills were at fault. Rightfully so, most of the discourse centered on protecting patients from surprise bills but lacked the understanding of who they needed protection against.

Surprise bills occur because certain providers deliberately remain out-of-network to maximize leverage and extract higher payments. By ignoring provider responsibility, the conversation made it seem as though patients were merely caught in a crossfire between two equally responsible parties. In truth, patients became collateral damage in a business model designed by providers to exploit gaps in insurance networks and to force payers into paying inflated charges.

The Solution: Expand the No Surprises Act to Protect Against High Costs.

To better protect patients from gaps in the No Surprises Act, Congress must fix the arbitration process and improve the law. Here are a few options:

First, end surprise billing for emergency ground ambulance services. Congress should enact the recommendations from the Ground Ambulance and Patient Billing Advisory Committee by designating these services as essential health benefits, limiting patient cost-sharing, and capping reimbursement as a percentage of Medicare.

Second, improve the dispute resolution process to even the playing field and limit abuses. Congress should require arbitrators to use the median in-network amount as the most critical consideration in determining payment resolution and add Medicare rates into their consideration. It should also add a screening process and improve the online portal, which starts the dispute process, to weed out ineligible filings like Medicare disputes. Performance metrics for the arbitrators would also help improve eligibility accuracy, timeliness, and fairness. Lastly, arbitrators should be barred from considering previous out-of-network rates, and providers should face harsh penalties for submitting claims that are inconsistent with law including attempts to resubmit a dispute in violation of the mandatory 90-day “cooling-off” period.

Third, replace the dispute resolution process with a benchmark rate based on the in-network median. Return to the original bipartisan idea: set a clear, predictable payment standard based on the median in-network rate. This reduces administrative costs, prevents gaming of arbitration, and reins in out-of-control provider charges. While it may be difficult to immediately replace arbitration, steps can also be made to put a higher emphasis on the median in-network rate throughout the process and make it less biased towards providers.

Fourth, cap all out-of-network reimbursement to incentivize network participation. Congress should implement a hard cap on what providers can charge out-of-network, set as a percentage of Medicare rates to discourage providers from staying out-of-network as a business strategy.

Importantly, Congress should also reject proposals that undermine the law. Efforts are underway, both through legislation and litigation, to weaken the No Surprises Act. In Congress, the No Surprises Enforcement Act was introduced to further tilt the scales towards providers, and it should be opposed.18 While enforcement of the No Surprises Act is important, the legislation only increases penalties for patients’ health plans for failure to meet deadlines, with no changes for how providers comply. While the arbitration process already favors hospital chains and private equity-backed physicians over patients, Congress should reject legislation that would tip the scales further away from the interests of patients.

The Bottom Line

The No Surprises Act was a major win for patients. However, there are significant gaps in the law. Without action to close loopholes within the law and stop abuse of the system, these gaps will play a role in rising costs and patients being hit with astronomical medical bills. Congress must act now to protect patients and lower health care bills.

Author: Darbin Wofford, December 17, 2025.

Former Deputy Director of Health Care

1. Pollitz, Karen. “ No Surprises Act Implementation: What to Expect in 2022.” KFF, 10 Dec 2021. https://www.kff.org/affordable-care-act/issue-brief/no-surprises-act-implementation-what-to-expect-in-2022. Accessed 9 Dec 2025 and Chhabra, Karan R., et al. “ Most Patients Undergoing Ground And Air Ambulance Transportation Receive Sizable Out-Of-Network Bills.” Health Affairs, 15 Apr 2020. https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2019.01484. Accessed 9 Dec 2025.

2. Renken, Elena. “Study: 1 In 5 Patients Gets A Surprise Medical Bill After Surgery.” NPR, 11 Feb 2020. https://www.npr.org/sections/health-shots/2020/02/11/804906330/study-1-in-5-patients-gets-a-surprise-medical-bill-after-surgery#:~:text=(Twenty%20percent%20of%20inpatient%20admissions,on%20the%20shoulders%20of%20patients. Accessed 9 Dec 2025.

3. Mercado, Darla. “This teacher wound up with a $108,951 medical bill. When to battle your insurer.” CNBC, 27 Aug 2025. https://www.cnbc.com/2018/08/27/this-teacher-wound-up-with-a-108951-medical-bill-when-to-battle-your-insurer.html. Accessed 9 Dec 2025.

4. “No Surprises Act.” Georgetown University Law Center. https://litigationtracker.law.georgetown.edu/issues/no-surprises-act/. Accessed 9 Dec. 2025.

5. “Roll out of Independent Dispute Resolution Process for Out-Of-Network Claims Has Been Challenging.” U.S. Government Accountability Office, Dec 12 2024. https://www.gao.gov/products/gao-24-106335. Accessed 9 Dec. 2025.

6. Hoadley, Jack et al. “Independent Dispute Resolution Process 2024 Data: High Volume, More Provider Wins.” Health Affairs, 11 June 2025. https://www.healthaffairs.org/content/forefront/independent-dispute-resolution-process-2024-data-high-volume-more-provider-wins. Accessed 9 Dec 2025.

7. Ibid.

8. Hoadley, Jack and Kevin Lucia. “Surprise Billing: Volume Of Cases Using Independent Dispute Resolution Continues Higher Than Anticipated.” Georgetown University, 18 Aug 2023. https://chir.georgetown.edu/surprise-billing-volume-of-cases-using-independent-dispute-resolution-continues-higher-than-anticipated/. Accessed 9 Dec 2025 and Wofford, Darbin. “Revenue Cycle Managers—A Hidden Middleman Increasing Health Care Costs.” Third Way, 23 July 2025. https://www.thirdway.org/memo/revenue-cycle-managers-a-hidden-middleman-increasing-health-care-costs. Accessed 9 Dec 2025.

9. Hoadley, Jack and Kennah Watts. “The Substantial Costs Of The No Surprises Act Arbitration Process.” Health Affairs, 25 Aug 2025. https://www.healthaffairs.org/content/forefront/substantial-costs-no-surprises-act-arbitration-process. Accessed 12 Dec 2025.

10. Ibid.

11. Hargraves, John and Linsay Sarfo. “Ambulance Trends over 10 Years (2012-2021).” Health Care Cost Institute, 12 Oct 2023. https://healthcostinstitute.org/all-hcci-reports/ambulance-trends-over-10-years-2012-2021/. Accessed 9 Dec 2025.

12. Adler, Loren et al. “Ground Ambulance Billing And Prices Differ By Ownership Structure.” Health Affairs, 18 Jan 2023. https://www.healthaffairs.org/doi/10.1377/hlthaff.2022.00738. Accessed 9 Dec 2025.

13. “Report on Prevention of Out-Of-Network Ground Ambulance Emergency Service Balance Billing.” Ground Ambulance & Patient Billing Advisory Committee, 29 Mar 2024. https://www.cms.gov/files/document/report-advisory-committee-ground-ambulance-and-patient-billing.pdf. Accessed 9 Dec 2025.

14. Harden, Madison. “ Expanding the No Surprises Act to Protect Consumers from Surprise Ambulance Bills: Map of State Laws.” The Commonwealth Fund, 16 June 2025. https://www.commonwealthfund.org/publications/maps-and-interactives/expanding-no-surprises-act-protect-consumers-surprise-ambulance. Accessed 9 Dec 2025.

15. Stovicek, Nadia and Jack Hoadley. The Commonwealth Fund, 26 Sep 2024. https://www.commonwealthfund.org/blog/2024/states-forge-ahead-protect-consumers-advisory-committee-recommends-federal-action. Accessed 9 Dec 2025.

16. ”S.1895 - Lower Health Care Costs Act." Congress.gov, 19 June 2019. https://www.congress.gov/bill/116th-congress/senate-bill/1895/text#toc-idC58C0FF70FE142EA991B25700FF481D8. Accessed 9 Dec 2025.

17. Sullivan, Peter. "Turf war derails bipartisan push on surprise medical bills." The Hill, 12 Dec 2029. https://thehill.com/policy/healthcare/474520-turf-war-derails-bipartisan-push-on-surprise-medical-bills/. Accessed 9 Dec 2025.

18. “S.5535 - No Surprises Act Enforcement Act." Congress.gov, 16 Dec 2024. https://www.congress.gov/bill/118th-congress/senate-bill/5535/text. Accessed 9 Dec 2025.

When a Law to Protect Patients Ends Up Costing Them More

DC Journal

If you’ve gone to a hospital that’s in your insurance network, you probably assume every doctor you see there is also in-network. That used to be a risky assumption. Before 2022, many patients were shocked to get massive medical bills after getting care from doctors who, unknown to them, weren’t in their insurance network, even though the hospital was.

To fix this, Congress passed the No Surprises Act. It was designed to protect patients from these surprise bills, and to its credit, it has primarily done so. While the law has helped patients avoid unexpected charges on the front end, it has created new problems behind the scenes that could end up costing you in the long run.

Here’s what’s happening: Even though the NSA stops doctors and hospitals from billing patients directly when there’s a disagreement over pricing, it doesn’t stop them from going out of network. When doctors and insurers can’t agree on how much a service should cost, the law sends them into a kind of arbitration process, like we’ve seen in baseball contract disputes, where each side submits a number, and a third party picks one.

This process is called Independent Dispute Resolution (IDR). Unfortunately, it hasn’t worked as intended.

So far, arbitrators have mostly sided with hospitals and doctors (more than three-fourths of the time). They’re choosing prices that are often 50 percent higher than what’s normally paid for in-network care. That might not sound like your problem, after all, you’re not paying that bill out of pocket.

Here’s the catch: Higher prices in arbitration mean higher costs for everyone, including through higher insurance premiums. And it’s getting expensive. One estimate says IDR has added at least $5 billion in costs to the healthcare system. These extra costs eventually land on the shoulders of businesses, employers and families — in other words, you.

Even worse, this system creates a dangerous incentive. Some doctors are choosing to stay out-of-network on purpose, knowing they’ll likely get more money in arbitration than they would under a negotiated insurance contract. If this keeps up, more doctors will stay out-of-network, making it harder for people to find covered, affordable care.

There are ways to fix the system. Arbitration decisions should be tied more closely to the average in-network rates that insurance companies pay. That would keep things fair and prevent inflated payouts. More important, hospitals should be required to contract with in-network doctors, especially in emergency rooms and hospital-based specialties. If a hospital is in-network, the care you get there should be, too.

The No Surprises Act was a well-intentioned law. It stopped the worst billing abuses. However, the current arbitration process is placing alarming pressure on the system, resulting in higher costs and fewer choices. If we don’t fix it soon, these “surprise medical bills” may just sneak in through the back door, as higher premiums and narrower networks.

It’s time to hold hospitals and doctors accountable and ensure that patient protections don’t become loopholes for profit. Patients should be protected not only from surprise medical bills but also from rising costs.

Author: Richard Popiel, December 16, 2025.

Richard Popiel is a recognized healthcare delivery expert. He wrote this for InsideSources.com.

No Surprises, For Real

RealClear Health

As a nurse, a Member of Congress, Chair of the Health sub-committee on the Veterans’ Affairs Committee, and as a consumer safety advocate, much of my life has been devoted to fighting for Americans to have affordable, transparent, quality healthcare.

The No Surprises Act (NSA) was an important step forward in that effort. It was intended to protect patients from being blindsided by surprise medical bills from providers. But a loophole in its implementation is undermining the benefits it was meant to deliver, as healthcare providers continue to exploit the system.

Picture a family taking their child to the hospital for a scheduled procedure. They do everything right, making sure they go to an in-network hospital. But a month later, they receive a bill for thousands of dollars from an out-of-network provider that the hospital contracts with.

These bills happen when someone went to an in-network hospital, reasonably assuming that every one of their providers would also be in-network only to find out later that someone involved in their care, such as an anesthesiologist, an orthopedic surgeon, or a neurologist, was not in their insurance network.

The NSA aimed to protect patients from receiving these surprise medical bills. One of the ways it sought to accomplish this was by establishing a baseball-style arbitration system, or the Independent Dispute Resolution (IDR) process, to settle payment disagreements between insurers and providers.

When an out-of-network provider and an insurance plan can’t agree on the reimbursement rate for a covered service, each side submits a final offer, and an independent arbitrator picks one. Importantly, this behind-the-scenes process was meant to keep patients out of complex billing disputes and ensure fair outcomes. Decisions were supposed to be based on the market average for a given medical service or device. But, in many cases, the opposite has happened.

Some providers have figured out how to exploit IDR for their own gain. Certain providers file huge numbers of IDR cases for non-emergent procedures performed at in-network hospitals. The Department of Health and Human Services initially projected they would process 22,000 disputes annually. Instead, they have been swamped exponentially, buried by 1.1 million claims per year.

Not only that, when decisions are eventually rendered in those disputes, providers have overwhelmingly benefitted. For 2024, the average amount awarded when providers won cases was nearly 450% of the median in-network payment rate for a service. In some cases, it was even more. No wonder providers initiated at least 85% of disputes.

And most of these disputes don’t even stem from surprise medical situations but planned surgeries in markets where in-network options already exist. This practice turns a law meant to protect patients into a tool for increasing revenue.

These inflated payments do not disappear. Health insurers and employers faced with rising costs from these settlements have to raise premiums for everyone. The result is that the financial burden is shifted to employers, small businesses, and the millions of working Americans with insurance.

The incentive shift is also weakening insurance networks. Because arbitrators often award more than standard in-network payments, some hospitals and physician groups choose to stay out of network, finding it more profitable. This reduces their motivation to negotiate in-network contracts. Fewer in-network provider choices and more reliance on arbitration drive up costs, and those costs ultimately flow back to consumers.

Right now, these practices are happening in the shadows of the NSA’s good intentions. Bringing them into the light is step one.

But aligning incentives with what’s best for patients is the only way to ensure the No Surprises Act is sustainable for the long term.

Patients who choose in-network hospitals should have in-network care teams whenever possible. Facilities that allow contracted providers to exploit the IDR process should not benefit financially. When in-network options are available and not used, reimbursement should be adjusted, and other contractual tools, including possible termination, should be used to keep networks strong and effective.

The goal is to protect affordability for American employers and families by directing care to participating providers where clear in-network options exist. This is not about restricting patient access. It’s about closing a loophole that is driving unnecessary costs.

Healthcare should provide certainty, not anxiety. Every family deserves to know that a trip to the hospital will not lead to financial hardship. The loophole in the No Surprises Act threatens this basic promise. There really should be no surprises. Not in the hospital bill, and not in rising premiums.

Regulators and lawmakers must act now to make sure the law lives up to its purpose, so no American faces surprise costs in our healthcare system.

Ann Marie Buerkle is a former nurse and congresswoman who served as the Commissioner and Acting Chairwoman of the Consumer Product Safety Commission.

Why Patients are getting hit with surprise hospital fees for routine medical care

PBS News

In recent years, hospital systems have been buying up medical practices at a rapid pace. Now, patients getting routine medical care are being hit with high costs and unexpected hospital fees — even if they never visited a hospital. Special correspondent Megan Thompson reports.

John Yang:
The next time you go to the doctor’s office, you may not know whether or not they’re affiliated with a hospital system. If they are, your bill for a routine visit may include some surprising extra charges fees that go to the hospital even if you never stepped a foot inside it. Special correspondent Megan Thompson has our report.

Megan Thompson (voice-over):
In 2016, Jess Ayers and her family moved from New Jersey back to her home state of Minnesota. Ayres set about making appointments with new doctors for her three children, especially her daughter, who needed regular eye exams.

Jess Ayers:
She was diagnosed with strabismus, which is essentially a lazy eye.

Megan Thompson (voice-over):
So they took her to an ophthalmology practice at this clinic in Minneapolis that had been recommended by their old doctor in New Jersey. After the checkup, Ayres was surprised to receive two bills, one for the physician’s fee and one for hospital charges totaling $176 AERs.

Jess Ayers:
It was very puzzling and frustrating.

Megan Thompson:
Had you gone to a hospital?

Jess Ayers:
No, we had not gone to a hospital. Right. This was a doctor’s office.

Megan Thompson (voice-over):
Ayres discovered the doctor’s office was part of a hospital system called M Health Fairview, one of the largest health systems in the state. So Ayres, who works in healthcare communications, had to pay something called a facility fee.

Jess Ayers:
I was dumbfounded because I’d never heard of it, and having worked in health care for a long time, I was taken aback.

Megan Thompson (voice-over):
She’s not alone, says Christine Monahan, an expert on facility fees at Georgetown University’s center on Health Insurance Reforms.

Christine Monahan, Georgetown University:
Facility fees are particularly pernicious because there are these high, often surprising bills that are not really adequately covered by our insurance.

Megan Thompson (voice-over):
Monahan says hospitals have traditionally charged facility fees to help cover their overhead costs. But more and more they're charging the fees for routine outpatient care.

Christine Monahan:
Two things are at play. One is that hospitals are increasingly acquiring physician practices. More and more places you go to will be affiliated with the hospital.

Megan Thompson (voice-over):
In fact, between 2012 and 2024, the percentage of doctors employed by hospitals or health systems more than doubled to 55 percent, which helps explain why it seems more Americans are being charged.

Christine Monahan:
But we're also seeing them more. Consumers are feeling them more because we're seeing deductibles increase in our insurance coverage. And so more and more you might be directly responsible.

Megan Thompson (voice-over):
Nationwide, insurance deductibles have increased by nearly 50 percent in the last decade. Jess Ayers current insurance plan has a high deductible of $10,000 for her family of five.

Jess Ayers:
You know, there's a lot of those types of bills. They come in every which way and it's a little bit like death by a thousand. Paper cuts.

Megan Thompson (voice-over):
Kaitlin Johnson of Minneapolis says she was prepared for a facility fee when she took her eight-year-old daughter for a panel of 40 allergy tests last summer at this M Health Fairview clinic. But she was not prepared for how much the actual tests would cost.

Kaitlin Johnson:
The total they charged to insurance was $24,400.

Megan Thompson:
$24,000.

Kaitlin Johnson:
Yes.

Megan Thompson (voice-over):
Insurance paid almost $19,000, and Johnson was left to pay more than 5,400.

Megan Thompson:
I mean, what went through your head when you saw that bill?

Kaitlin Johnson:
Shocked and really confused because, you know, part of me felt like, how did I not know that this was such an expensive test?

Megan Thompson (voice-over):
It turns out it's actually not.

Kaitlin Johnson:
I'm just calling to see if I can get some pricing information.

Megan Thompson:
Johnson called around to allergy clinics not affiliated with hospitals and asked about a panel of tests similar to what her daughter had.

Woman:
Testing typically runs about $1,827.

Woman:
Could run anywhere from 800 to 1.800.

Megan Thompson (voice-over):
And that's the price before insurance kicks in. Johnson thought her clinic had made a mistake, but they assured her they had not. Saying there is a big difference between hospital pricing and freestanding clinic pricing. So now she's fighting the bill.

Kaitlin Johnson:
This test was outrageously expensive and seemed extremely out of line.

Megan Thompson:
High prices, Christine Monahan says, are another consequence of hospitals consolidating and buying up independent practices. The larger they are, the more negotiating power they have with insurance companies.

Christine Monahan:
The greater the market power that a hospital has, the higher prices they charge for their services.

Megan Thompson (voice-over):
High procedure prices and facility fees are helping drive up the cost of hospital care, which has been growing about twice as fast as inflation and outpacing physician services and prescription drugs.

What do they pay for?

Megan Thompson (voice-over):
To understand what's behind the surging prices, we spoke to Molly Smith of the American Hospital Association.

Molly Smith, American Hospital Association:
First and foremost, there is no place in the healthcare system like a hospital. We uniquely provide the highest level of care.

Megan Thompson (voice-over):
Smith says operating hospitals is expensive with their round the clock emergency departments, top of the line medical equipment and highly trained specialists.

Megan Thompson:
A patient walks into a doctor's office for routine care and they're not using any of those hospital resources. So you can kind of understand why they would say, why am I paying for them? I'm not getting anything.

Molly Smith:
But I do think everyone needs to understand what it takes for hospitals and health systems to maintain access to care in their communities 24 hours a day. When you need your emergency department in the middle of the night, you need it to be open and available.

Megan Thompson (voice-over):
Smith says inflation has made it all the more expensive, and hospitals are not being reimbursed enough by insurers to cover all the costs.

Molly Smith:
Insurers payers are squeezing providers to the point where they are no longer financially stable. For every dollar that a hospital spends on staff on medical supplies, Medicare only reimburses them $0.82. They have to make up that other $0.18 somewhere else.

Megan Thompson (voice-over):
But state legislatures are increasingly cracking down, saying that gap shouldn't be made up by raising costs for routine care.

Christine Monahan:
We've seen 20 states nationwide take some type of action to regulate facility fee billing.

Megan Thompson:
And when it comes to reining in prices for procedures, a bill proposed in New York state would be the first to cap prices at hospital outpatient clinics for people with commercial insurance, people like Kaitlin Johnson with her daughter's $24,000 allergy test.

In a statement to PBS News Weekend, M Health Fairview said, we understand that health care billing can be complex, and we recognize that the cost of care a significant concern for many individuals and families.

After eight months of Johnson fighting her bill and after inquiries from PBS News Weekend, M Health Fairview finally agreed to waive her balance. They also told her they've decided to reduce their price for allergy tests by more than 80 percent.

As for Jess Ayers, she found she could avoid the facility fee by driving her daughter to a different clinic 40 minutes away in a far off suburb. Even though it's the same doctors and health system.

Jess Ayers:
You almost like had to shake your head and be like, what?

Megan Thompson (voice-over):
Luckily, Ayers could afford to pay her bill, but she still worries about those who are less well-off and about people like her parents who live in rural northern Minnesota, a two hour drive from their doctors.

Jess Ayers:
And there's a lot of country out there and there are a lot of people who are further from care. And if they only have a choice to go to a facility that does charge a hospital fee, what then? How is that fair?

Megan Thompson (voice-over):
For PBS News Weekend, I'm Megan Thompson in Edina, Minnesota.

Author: Megan Thompson, April 12, 2025.

Megan Thompson shoots, produces and reports on-camera for PBS NewsHour Weekend. Her report “Costly Generics” earned an Emmy nomination and won Gracie and National Headliner Awards. She was also recently awarded a Rosalynn Carter Fellowship to report on the issue of mental health. Previously, Thompson worked for the PBS shows and series Need to Know, Treasures of New York, WorldFocus and NOW on PBS. Prior to her career in journalism she worked in research and communications on Capitol Hill. She originally hails from the great state of Minnesota and holds a BA from Wellesley College and a MA in Journalism from New York University.

When Private Practices Merge with Hospital Systems, Costs Go Up‌‌

Yale Insights

Private practices are vanishing as more doctors join large hospital systems. This increasing consolidation is reducing competition and raising prices, according to a study co-authored by Yale SOM’s Fiona Scott Morton.

Historically, physicians worked independently of—if in partnership with—hospitals. But increasingly, doctors are selling their practices to hospital systems, as well as private equity firms and insurance companies. What does it mean for patients and what they pay for healthcare when their doctors are employed by a hospital system?

The effects of hospital systems acquiring physician practices are hard to determine, because until now, there has been no comprehensive source of data about these mergers and the effects of integration on pricing can be hard to isolate. New research by Yale SOM economist Fiona Scott Morton tackles these challenges, determining the scale of hospital-physician mergers and examining their effects on pricing. In their study, Scott Morton and her co-authors—Yale economist Zack Cooper; Stuart V. Craig and Ashley T. Swanson of the University of Wisconsin–Madison; Aristotelis Epanomeritakis of Harvard University; Matthew Grennan of Emory University; and Joseph R. Martinez of the University of California, San Francisco—found that these integrations significantly increase prices for consumers, because competition decreases.

To Scott Morton, these findings are a wake-up call for regulators. “States haven’t been enforcing [antitrust laws] to the extent that they could,” she says. “I think there’s a lot of good that could be done with some incremental enforcement.”

Mergers between hospital systems and physicians in private practice are what antitrust experts call “mergers of complements” or “non-horizontal mergers.” These aren’t horizontal mergers, because doctors aren’t competing with hospitals, but they aren’t quite vertical either, because doctors aren’t suppliers to hospitals.

In general, scholars expect mergers of complements to have positive effects. Imagine, for example, a car maker decides it wants to own the software that will go into its vehicles. Rather than keeping its future design plans a secret from its software maker, “I can talk to them, and they can start thinking about what cool software could be used with my hardware. So we could do things together that we can’t do apart,” Scott Morton explains. Non-horizontal mergers can also reduce prices: “If I mark up my car and you mark up your software, then the [buyer] has two markups to pay, whereas if the hardware buys the software and makes a bundle, then they internalize that problem.”

But Scott Morton and her co-authors suspected healthcare might function differently. For example, there’s no reason to believe healthcare quality would improve after integration; after all, between navigating different insurance companies and referring patients to different specialists and hospitals, “doctors are rather good at providing care across corporate boundaries,” she says. And because healthcare is geographically constrained—patients don’t want to travel long distances to see a doctor—regional consolidation could increase prices.

To study hospital–physician mergers more closely, the researchers first had to contend with an informational challenge. “Everybody knew, anecdotally, that these transactions were happening and that there were a lot of them,” Scott Morton says, “but we just couldn’t measure them.” Hospital acquisitions of private practices are generally small enough transactions that hospitals aren’t required to report the purchases to regulators.

So, in the absence of a single comprehensive source of data, the team developed a workaround. Using administrative data from Medicare, hospital surveys, physician directories, and filings with the Securities and Exchange Commission, they trained a machine-learning algorithm to identify when a physician had moved from private practice to a hospital system. The researchers tested the algorithm’s results against verified data about mergers and found it achieved 97% accuracy.

When they set the algorithm loose on national data from 2008 to 2016, it identified a striking degree of integration—overall, the share of doctors employed by a hospital grew from 27.5% to‌ 47.2% during that span. ‌

To understand how this integration was affecting prices, the researchers looked at childbirths, which account for a large share of both commercial hospital admissions and healthcare spending. They gathered data on pricing—that is, how much doctors and hospitals were charging insurers—from a large private insurance company. Then the researchers looked at OB-GYNs who had integrated with a hospital system in 2013–2014, and compared the prices those doctors and hospitals charged two years before and two years after the merger. To ensure they were isolating the effects of integration, they also compared these doctors and hospitals to otherwise similar doctors and hospitals that had not integrated. ‌

Both hospitals and doctors charged more after integration, the researchers discovered: hospital prices for labor and delivery increased by 3.3% ($475, on average), while physician prices increased by 15.1% ($502, on average).‌

These are “substantial price increases,” Scott Morton says. “You may say, it’s only 3%. But this is 3% of a large hospital bill. And healthcare is already 19% of GDP. It’s giant.”‌

And this uptick in price did not reflect an improvement in healthcare quality as far as the researchers can determine. After examining common measures of quality for childbirths, including hospital readmission and C-section rates, the researchers found no improvements in the years after integration.‌

As the researchers continued analyzing their results, they found statistical signs of three different anticompetitive mechanisms that explained the price increases they observed.‌

The first of these is called foreclosure. Before integration, an OB-GYN in solo practice might refer their patients to several hospitals in the area for labor and delivery. After integration, however, the doctor might feel pressured to steer their patients to deliver within their hospital system. “That’s foreclosing those doctors and patients from choosing between hospitals,” Scott Morton explains. This gives the hospital and the doctor more power in the market, and therefore the ability to raise prices. ‌

The second is called recapture. If a physician in private practice is charging too much, an insurance company might refuse to include them in their network. “After the merger, tossing out the physician means tossing out the hospital,” she says. This might cause consumers to switch insurers so they can remain with their preferred doctor and hospital—“so a physician will recapture those people.” Once again, the doctor and the hospital can get away with raising prices. ‌

The third mechanism is simply market concentration. Over time, if a hospital system acquires enough private practices, “there is a horizontal impact of these [non-horizontal] mergers,” Scott Morton explains. “If the hospital already owns a couple of obstetricians, and buys another group, then those obstetricians become horizontally joined….and we find prices go up for that reason.” ‌

The researchers found further evidence of reduced competition when they looked at another group of doctors. Prices for doctors who had already integrated with a hospital system increased by 9% after the hospital acquired more doctors in their specialty. Nothing changed for these already-integrated doctors; they were the same doctors working at the same hospitals. The only plausible explanation for their ability to charge higher prices is a reduction in competition. ‌

To Scott Morton, these results call for renewed attention from regulators. States could, for example, require medical organizations to submit information about their ownership and physician affiliates, which would make it far easier to track hospital-physician mergers. Regulators could also require a waiting period before such mergers, “so that the state can assess for itself whether that transaction would be harmful.” A small task force at the federal level could even advise state regulators in making these assessments. ‌

And it’s important, she argues, to draw attention to the larger effects of small transactions in local markets: “States as well as citizens care a lot about having those prices be low and markets be efficient and working well.” ‌

Author: Susie Allen‌, September 26, 2025.

Did your doctor’s office charge you a ‘facility fee’? Here’s what to know.

NBC News

Facility fees, often associated with inpatient hospital stays, are becoming more common for outpatient doctors’ appointments.

In Minnesota, a family received an unexpected charge of over $400 after they took their daughter to the doctor for stomach pain. In Ohio, a man was billed $645 extra for an ear, nose and throat specialist. In New Hampshire, a resident was charged an additional $1,000 fee for an appointment with a urologist.

Across the country, patients are expressing frustration about “facility fees” — charges that a wide range of hospital systems add to bills for appointments at facilities they own, including doctors’ offices offering routine care.

Hospitals can charge facility fees even when a patient hasn’t set foot in a hospital. More than a dozen patients who expected their insurance to cover most of the cost of their appointments at outpatient doctors’ offices told NBC News they were blindsided by the fees, which are billed on top of the cost of seeing medical providers and can easily run into the hundreds of dollars.

The charges have become more prevalent in recent years as more physicians are employed by hospitals and as insurance plans leave patients paying more for care before their coverage kicks in. In some communities, there is so much health care consolidation that it’s hard to find practices that don’t charge facility fees.

Researchers say patchwork laws to regulate the fees haven’t kept up.

“In most states and situations, there aren’t really limits on how high they can go,” said Christine Monahan, an assistant research professor at the Center on Health Insurance Reforms at Georgetown University, who has studied facility fees.

Hospitals argue facility fees are necessary to fund the higher level of care they say they provide at their outpatient doctors’ offices, as well as to help maintain 24/7 services such as emergency rooms. The American Hospital Association says facility fees should be covered by insurance companies, while insurers say the fees unnecessarily inflate the cost of care without improving its quality.

Here’s what consumer advocates and health policy experts say patients should know about facility fees.

Before your appointment: What to ask

Experts recommend you ask every time you book an appointment whether there is a facility fee — even for physicians you have seen before. A doctor’s office ownership, hospital affiliation or policies may have changed since your last visit.

If you are told there will be a facility fee, ask for a good-faith estimate of what the anticipated charge will be, said Patricia Kelmar, senior director of health care campaigns at the U.S. Public Interest Research Group, a consumer advocacy organization.

And don’t assume your insurance will cover the bill.

Last year, Melissa Finnegan, of St. Paul, Minnesota, was charged a facility fee of $423.15 for an appointment with a pediatric gastroenterologist for her 3-year-old. When she tried to fight it, she discovered neither the health system nor her insurance company was willing to budge.

“I put off paying it for as long as I could,” she said.

When you get the bill: How to make sense of the charges

If you receive an unexpectedly large medical bill after an appointment, call the billing office to ask for an itemized bill to understand the charges. Outpatient facility fees may be listed under other names, such as a “clinic” fee. In office signs and other disclosures about facility fees, hospitals may refer to the practice as “provider-based billing,” which means patients’ bills can be split into two separate charges: one for the physician’s services and one for visiting the facility.

“People see the bill and just assume, because it’s on their bill, that they’re going to have to pay it,” said Eric Waskowicz, senior state policy manager at United States of Care, a nonpartisan organization that fights for affordable health care.

But in some cases, you may not have to pay. Insurers suggest patients wait until they receive their explanation of benefits so they can review what part their plans will cover and they don’t accidentally overpay.

You should also check the laws in your state to make sure you were correctly charged: Some states ban facility fees for telehealth visits, for example, while others prohibit facility fees for preventive services or at certain types of medical offices.

“Know what the law is, and then use it if you can to protect yourself from that fee,” Kelmar said.

The American Hospital Association advises patients to familiarize themselves with their insurance plans’ coverage and says that if they’ve received unexpected facility fee charges to confirm that their insurance has “appropriately processed” their claims.

What to do if you can’t afford to pay

If you can’t afford to pay a facility fee, try calling the medical provider’s office to see whether the charge can be removed. If that doesn’t work, talk to your insurance company, Kelmar said. Insurance may be able to work with the billing office to reduce your out-of-pocket responsibility.

There are other options for those who can’t pay. Sometimes billing departments will give discounts to people who offer to pay smaller amounts immediately, rather than pay the larger amounts over time.

Patients can also ask about paying the cash price, instead, meaning the charge they would have incurred if they didn’t have insurance, said Monahan, the Georgetown expert. The cash price might be lower.

If that doesn’t work, search for a health care advocate in your state, Waskowicz suggested.

“To the extent it’s possible, they are able to work with insurance providers to see if they can get that fee waived,” he said.

In the meantime, keep in touch with the billing office, Waskowicz added. If you are actively contesting the bill, chances are lower that it will be sent to collections.

Kelmar said that if you can’t avoid a facility fee and are struggling to pay, don’t put the balance on a credit card. Instead, work out a payment plan directly with the provider, ideally with low or no interest.

What to do ahead of your next appointment

If you want to avoid facility fees in the future, try to find an independent doctor’s office that isn’t owned by a hospital.

That isn’t always easy: In West Covina, California, Todd Bash, 60, needed injections for a spinal problem and ended up being billed facility charges of over $450 out of pocket for a pain specialist. He then made dozens of calls trying to find a different physician who could administer the injections. But he said all the doctors’ offices he reached out to were affiliated with hospitals or didn’t take his insurance.

Authors: Elizabeth Chuck and Maite Amorebieta, July 24, 2025.

Elizabeth Chuck is a reporter for NBC News who focuses on health and mental health, particularly issues that affect women and children.

Maite Amorebieta is a senior investigative producer with the NBC News Investigative Unit.