I have spent 20 years working in out-of-network healthcare reimbursement. After reading the New York Times article "A $440,000 Breast Reduction? How Doctors Cash In on a Health Care Law," I felt the payer's use of the independent dispute resolution (IDR) process was not sufficiently scrutinized.
The article details how the No Surprises Act (NSA) helped shield patients from surprise bills by barring out-of-network clinicians from billing patients directly. Instead, these doctors can now bring their case to a federally vetted arbitrator, and if they win, the patient's insurer must pay the doctor's proposed amount. And the doctors have been winning: the arbitrators have ruled in favor of the doctors approximately 88% of the time, leading some to collect fees up to hundreds of times higher than what they could previously negotiate with insurers or what they could have gotten from patients.
This left me wondering if these admittedly high IDR provider awards were really a pain point for an insurance industry that routinely reports billions in profits.
Examining the Insurer-as-Victim Narrative
First, I agree that $440,000 for a breast reduction is unreasonable, and yes, there are many bad actors in the space. But the NSA was developed to protect patients, not to reduce the out-of-network payment precedent set by payers over the last two decades. Within the context of the reported $447.6 billion in revenue and $12.1 billion in net earnings for United Healthcare in 2025, $274.9 billion in revenue and $6 billion in shareholder net income for Cigna, and $197.6 billion in operating revenue and a returned $4.1 billion to shareholders for Elevance, the payer-as-victim narrative falls flat.
