Christopher Cook, D.O., FASA

John, to your first point, CA’s AB 72 was signed into law in Sept. ‘16 and is a state commercial insurance rate setting law at 125% of Medicare for OON non-ED services (ED services were already covered by a CA Supreme Ct case known as Prospect Medical Group case). The cumulative growth of ERISA health insurance for both employers and employees exceeded +44% from ‘17-‘25. MI’s law was enacted in ‘20 (HB 4459) and set a state benchmark for ED and other hospital services at 150% of Medicare. The cumulative increase in MI was 19% for ERISA based health care. Facts are stubborn things—and there is simply no proof that anyone has produced showing that benchmarking physician rates causes lower premiums—full stop.

Rep. Pallone (D-NJ) has issued his new bill to reform the #NoSurprisesAct and let me count my top 3-4 reasons why it is a trainwreck for physicians and hospitals (and wait until you see #4): 1. IDR would be eliminated in favor federal rate setting at the "qualifying payment amount" (QPA or initial payment determined by the health plan). There is no recognition here that the federal district and appellate courts (TMA I, II, III and IV plus 2 appellate court decisions, so 6-0 for the TMA) have found issues with the administration of the QPA and recently that the QPA rules should be void and have no legal effect due to health plans' inclusion of ghost rates and other QPA manipulations (TMA III US Court of Appeals for the Fifth Circuit, Aug. '26). The Rep. includes the CPI-U adjustment in his bill which is laughable as the current law requires it and few if any plans actually comply with the requirement. One reason--no real audits of the QPA (see #4 below). Why? The current CPI-U is +28% from a 2019 baseline. 2. No other factors would be considered in final payment--just blatant federal rate setting. NSA requires acuity of the Pt, prior contract rates, qualifications of the clinicians and one can use the Transparency in Coverage (TiC) data which shows market rates among other factors for the IDRE to consider--none of that for Mr. Pallone. Ask your colleagues in CA and MI how they like state based rate setting for applicable OON claims? 3. Another laughable provision--payment w/in 30 days but no interest or penalties--and yes that is in the current NSA. As I have cited so many times here, the data is overwhelming that the plans are in systemic non-compliance with payment. Why would they comply in the future without enforcement, penalties or interest? 4. My favorite--no judicial review of the QPA. The plans have the ultimate and unquestionable power to set the QPA and never be questioned by any physician or hospital in court. Oh, CMS can audit and that's true today. 4+ years ago CMS announced they were conducting over 20 audits, one has been announced in that time and the plan was out of compliance with setting the QPA. To the physician and supporting community--time to get ready to become active again to preserve and enhance the NSA. If that bill above becomes law, independent practice as we know will largely cease for groups actually accepting insurance and patient access to care will greatly suffer. democrats-energycommerce.hou…