Plan X is contractually obligated to pay for Sally Smith’s appendectomy.
Fortunately for her, appendectomies are no longer performed without anesthesia, at least in the U.S.
For whatever reason, suppose your anesthesia group is not contracted with Plan X. Note that it does you a disservice to frame the situation such that you are “out of network” with the plan; rather, it is Plan X which failed to enter into a contract with your group. After all, they are contractually bound to pay for anesthesia services and what did they think the result would be if they didn’t have a contract with you?
For decades before the No Surprises Act, the answer was generally clear. Insurance plans paid a portion of the usual and customary rate with some argument, of course, over the amount. The patient paid the rest. No medical provider was forced to simply accept some amount that an insurance company thought was appropriate.
I understand that you and countless others are simply trying to get paid what you are worth, but you are doing it within the NSA system that is rigged against you.
It’s the entire system that you should be railing against.
And that system will become worse if the Lower Premiums, Faster Payments Act (H.R. 10788) becomes law, in which case there’d be no IDR process at all, just each plan’s QPA, calculated under a methodology not subject to judicial review.
The bottom line is that Plan X was contractually obligated and you were not. Yet you had no choice but to provide the care. Plan X failed to deliver what Sally Smith reasonably believed she was entitled to. If Congress wanted to protect her from that surprise, it should have passed a law obligating Plan X to pay in full. Instead, it passed a law that obligates you to pay (by way of a discount to which you never agreed). Forcing you to subsidize Plan X’s obligations had nothing to do with protecting Sally Smith; it had to do with protecting Plan X. How is that fair?
Like the misdirection employed by a great magician, the insurers have clinicians arguing over the details of IDR/QPA while, no matter the outcome, they are still picking your pocket.
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