All right. I think we're going to go ahead and get started. Thank you for those who decided we're worth more than just lunch, so we appreciate you sticking around. We're going to talk about the experience that we've had as the three of us through our organizations on how we've been really collaborative to support, as you can see, litigation as one of our advocacy strategies, but we do want to try to find a way to make this interactive because we think that there's a lot of what we'll talk about that may, while the details might not be the same as yours, some of the strategies and the reasons for some of this stuff might be the same as yours. We each need to disclose that we work for the organizations that are part of this effort, but other than that, we don't have any. I'm Sue Sedoria. I'm with the American College of Emergency Physicians. We have Paul Pomerantz, who's with the American Society of Anesthesiology, and Bill Thorwath, who's with the American College of Radiology. The framework for what we're going to talk about, and we put this into this, does this sound familiar? Have you worked in any kind of collaborative advocacy? Have you been trying to push back against constant disinformation about the things you're trying to actually do within some of that advocacy work? Have you had to take a multi-pronged focus to try to address what you're trying to tackle to the very many different audiences that you have to bring that to? Are you also trying to do some of this advocacy for your physicians who are feeling helpless against any number of people, the least of which for us was the insurance industry? Do you have a good tactic and a strategy for knowing when to involve your leaders or even when to take legal action? Those are the threads we think we're going to pull through this conversation, and we want to come back to some of these questions at the end, and that's where we really want to invite your ideas as much as your questions. What we're going to talk about is actually a broad timeline of some very early advocacy work that we were starting to already collaborate on way back in 2018, 2019, that really ramped up as we were coming into 2020, and at the very end, literally like December 27th, the No Surprises Act passed as part of an omnibus reconciliation bill. That could have been the end of a journey for us on trying to get this, but instead it actually was a reset on a whole different chapter in this journey on everything we were trying to do when it came to our aligned advocacy that led up to us by fall of 2021 suing the government for the implementation of this act, consistent and continued regulatory and messaging support throughout 2022, and even still now in 2023, while we've had some real wins, there's still actually not a victory yet in sight. Just so that you know what we're talking about here, we are talking about the No Surprises Act, which was named in response to what is considered a surprise medical bill. What is a surprise medical bill? You'll hear it described in any number of different ways, but at the heart and soul, it's simply the patient being caught in the middle of this growing gap between the cost of care that is provided by our physicians and our health systems, and then the money that is paid for that care by the insurer. We know that patients are getting increasingly caught in the middle of this challenge. Sometimes the patient's not even aware that the physician is out of network, and we all certainly represent specialties where you don't usually get a chance to talk to the patient about whether or not they're in or out of care when you're providing that care. It can happen when the patient hasn't met their deductible, or might even not be aware of the fact that their deductible for out-of-network care is now even higher than their deductible for in-network care. In our case, in all of our cases here, the physician is actually required to provide emergency care regardless of that patient's ability to pay. This is the EMTALA Act that really provides that safety net for our country that we're very proud of, but doesn't always pay for it. Certainly patients are getting increasingly caught in the middle of these sort of surprise bills when the insurer just continues to narrow and narrow and narrow the network, kicking out physicians that might have been in a network situation and now find themselves on the outside. I'm going to turn this over to Bill Thorwath, who is kind of here. I wasn't really here at the beginning of all this for our organizations. He certainly was, and is going to walk through a little bit more on sort of this protracted timeline that was leading up to this. Thanks very much, Sue. It really is a pleasure to be here with you all discussing something that honestly applies to all of your members, because this is not specialty-specific. Though your three specialties are sitting up here talking about it, it really applies to all physician providers. In 2018, I'll show you in a minute some of the lay press that was out there about these stories of people getting bills that they didn't expect. They may have gone to a hospital that they knew was in network, but then there was a physician provider on that medical staff that provided care that was out of network. So in February of 2018, Senator Cassidy had a workgroup forum that was looking at this, and again, I'll show you some of the public sentiment and news releases that incited that. February of 19, the Congressional Staff Briefing started, and actually our three organizations on a panel moderated by someone from the American College of Surgeons met with Congressional staff to say, our physicians wanted to be in network, but oftentimes the insurers were not really negotiating in good faith, so you did end up occasionally being out of network. That actually occurred in May of 2019, and as I say, that particular press, or meeting with the Congressional staffers, and at that time, you can see the bills here, House Resolution 3630 and Cassidy Bill 1531 in the Senate. The Senate HELP Bill in June of 19, again, was starting to consolidate that, and in the meantime, there was background work being done by Brookings and others that were making recommendations that were being tossed around by the various committees within Congress. So our legislative advocacy had already begun. And then, of course, when the Energy and Commerce passed a bill limiting, one of the things we wanted, our physicians wanted, was some sort of independent dispute resolution process within the bill to be sure that they had the opportunity to contest what they might feel was an inadequate payment. And in October, Ways and Means considered that, and all of that came together to, again, this will show you some flashes of some of the public press, lay press that was going on out there, and they were really using, quite frankly, oftentimes, hyperbolic stories in order to, and it gives you a good example of trying to control the messaging early, because as I say, the insurers really did a good job of getting out there and saying, oh, look at these terrible things that are happening, and as I say, when Senator Cassidy, as you see here on the right of the screen, met with the committees, they were juggling with several plans that, quite frankly, were not acceptable to the, and this is on autopilot, wait a minute, I'm sorry, I'm not pushing, let me see if I can go back, okay. So they were considering the Brookings recommendation, and that was to bundle all of the care done in the emergency room into one payment, including all the physician care and the hospital care, and we, of course, were resisting that. But so let me go ahead and let's concentrate, and what happens in 2020 that leads up to the passing of the No Surprises Act at the end of 2020, as Sue pointed out. As I say, these stories continue to be out there. A lot of insurance press was going out, and they were very much doing their best to control the messaging. The physicians were trying to describe this, and I think appropriately so. Our groups were trying to say, this isn't, these aren't surprise medical bills, these are inadequate networks, and we really wanted that message to get out there, but we could never get away from the verbiage of surprise medical bills. So before the No Surprises Act, patients really were sort of caught in the middle. They were sent a bill from care that had already been delivered by a provider that they may or may not have actually personally interacted with, but they were caught, and there was, you know, a lot of folks, quite frankly, who had some of these bills mounted up to very significant costs. The bill got the patient out of the middle, so that it banned balanced billing of the patient beyond their deductibles. The deductibles for out-of-network care had to be the same for where it provided in-network. Insurers had to print a policy on a policyholder's deductibles on their insurance card so they could know going in what their deductible was, and it was, of course, up to them to know how far along they were to meeting that deductible. The insurers had to make payments to the provider within 30 days. These were provisions that were very physician-friendly, and again, what we're going to be talking about more here is it established an independent dispute resolution process that was pretty well prescribed, very precisely described in that legislation, and there was no minimum dollar threshold. Many of us, and I can speak in radiology, many of our bills are quite low. If they set a threshold of $750, which was one of the ones that was requested, that would mean really no radiologist would ever contest a bill because it just wouldn't have made any sense, and then there were other factors. One thing that was in the bill was there was equal consideration for multiple factors. There's a list of, I think it's eight or nine different factors, but equally, and there was no predominant factor, and you'll hear more about that later. So how did this work? A physician submits a complaint, it's an out-of-network physician, submits a claim for payment. There's a difference between what they're charging and what the insurer is ready to pay, so that dispute starts now. They have now a 30-day time period during which they can try to resolve that between the two of them. If they're unable to resolve it, then they could request to go into independent dispute resolution. They would have to pay what was initially a $50 filing fee, and then they would agree upon a vetted mediator to look at this, and then each had to pay a second fee in order to get into the mediation, the second fee of which would be borne by the loser, if you will, of the dispute. You can see the charges that were part of that mediation fee. So the independent dispute resolution mediator, then, again, with each of them then modifying their fees or their proposal, this was a so-called baseball-type negotiation where you put in whatever you thought you were warranted as a physician or you were willing to pay as a provider, and they had, as I said, a limited time period for that to be decided by the mediator. So during that dispute resolution, the impartial reviewer looks at those two and has to pick one of those two numbers. They can't come up with an independent number that might be somewhere between the two, and then the loser pays not the filing fee but the mediation fee for both sides. So again, this gives you kind of an outline of how that process was supposed to work. The mediator was supposed to be equally considering the multiple factors that the legislation prescribed. And I'm not sure if I think we're on to Paul. Oh. Oh. Okay. So I was just napping after lunch. What's going on? No. So the rules were put forth here and go into the slide here. This was really a game-changer. So the legislation, we were largely satisfied with. The groups worked together. The legislation really accomplished what we were hoping it would. It took the patient out of the middle, also provided what we thought would be a fair process for looking at physician payment in the process. But that's not what really emerged in the rulemaking, and there were lots of problems in this. And so this essentially, and I think the scales of justice really demonstrate this, this really put a lot of power in the hands of the insurance industry. There was a big disconnect between the rule, between the law and the rules that were issued. And we saw problems right away from the day, from before the rules were implemented, but certainly from day one in terms of the implementation. Essentially the regulations elevated the QPA above other factors to be considered. The QPA is the Qualified Payment Amount. And it really gave the insurance company a lot of power to set a rate that could be arbitrary, and in fact set a rate that we found in many cases closer to Medicare or not even based in reality. One of the things we'll share with you is the use of something called ghost rates. So there's a lot of factors. The law requires the use of median market-based rates, but those could be gamed. It's very, in some ways, very arbitrary, and one of the ways it's gamed by the insurance industry is to incorporate what's called ghost rates, which are rates that appear in contracts. Let's say it's a primary care contract that may include anesthesia services or radiology services that are not actually used, but they appear in the contract and thus are averaged out, and so those began to appear in some of the rates. It was a clear violation of congressional intent. Over time, it will impact the payments for all services. It really became a de facto way of rate-setting for the commercial insurance industry. You know, we've lived with a fixed rate for Medicare and that, you know, having its implications for the viability of physician practices. Now we have really a rate-setting for private insurance and all the implications you can imagine for that. Insurers would have no reason to contract fairly. In fact, they were incentivized under these rules to drive physicians out of network. What we saw was a pattern of insurers sending notes to practices, letting them know that the No Surprises Act has now given the insurance company, in one case Cross Blue Shield, another place Cigna, another place UnitedHealthcare, saying that these rules now gave the authority to set rates below that that was established in the contract and thus move the provider out of network. And the other implication we felt was that it would drive consolidation, and I'll explain the reason for this, but primarily now the cash flow is affected, payment is affected, but in order to use the system of getting fair payment, of running a payment through the independent dispute resolution requires a lot of scale, requires the ability to withstand holdups in cash flow, things of that type. So it was really a game-changing rule that ran counter to congressional intent that really turned the whole insurer-provider sort of relationship upside down and gave really outsized power to the insurance industry, which was not the intent of Congress. So we made a decision to go with a lawsuit. This was not an easy decision, and I think each of our organizations were considering what options we had. Part of the challenge for us was Congress did its job. I can't go back to Congress. The regulatory agency, CMS, had really gone in a different direction. We assumed that they were heavily influenced by the insurance industry. We're not sure exactly what had happened, but clearly there was a disconnect between the regulatory interpretation and the law itself. It was interesting, around that time, and I think this was primarily right after the law was passed, late in 2021, November, December, and in fact I think we began looking at this in October, there was a lot of cries for legal action to test this regulatory framework. And you'll see in the next slide just how far and wide the lawsuits were. Not only affected our hospital-based services, but affected air ambulance, ambulance, anywhere where the provider or the physician was kind of hidden from the patient view. It's another good case where regulators were kind of separating physician interests, and really the ones taking the brunt of this were the hospital-based physicians. So what went into our calculation was the overt regulatory misinterpretation, the principle of the outsized influence, and as indicated earlier, this law, but primarily the regulatory framework, followed a long series of articles, both in the academic media, like the New England Journal of Medicine, as well as in the lay press, that really undermined the integrity of physician rates and bills. We already had just a lot of distrust about the interests of physicians in this, and kind of a false narrative that this was about protecting patients against really high bills. So some of the articles, some of the studies that were funded by the insurance industry really questioned the level of payment, the historical levels of payment made to emergency physicians, to anesthesiologists, and to radiologists, and it was in that kind of environment that we found that we were facing. So we felt that we needed to, our members were very upset. They were feeling the heat from this. We were already hearing from members who were being pushed out of network. They were feeling powerless in the whole effort. So we felt that it was important to stand up in a bold way and take legal action. The issue, of course, is suing the government is not an easy decision to come to. Knowing I was going to retire, I said, well, I'm willing to do it. So, and there were... And they said, we'll do it as long as somebody else doesn't with us. So it was really interesting at the time, because the AMA was feeling some heat to take action, and I'm sure we could keep a secret in this room, right? I mean, you guys are pretty good with this. So we had discussions with the AMA about doing a joint suit, but the AMA really wanted to go their own way. They may have had legitimate reasons for it. It's hard to do a suit with multiple parties, but we felt it was very important to represent our members in this effort. The AHA, American Hospital Association, also wanted to file a suit on this. So they filed separate suits in D.C. District Court and those suits were bonded together. The air ambulance industry also got involved. They wanted to file a suit also in D.C. So those three suits did eventually get bundled together. So what you see in this chart is the number of suits and the courts in which those were filed. The ACR, ASAP, ASA case was filed in Illinois, but there were also cases filed, as you can see, in Florida, D.C., and other, and New York and around the country. The ones that really stood the test of time, though, really occurred, and you'll hear in a second, in Texas. What happened with the others as time passed, as the courts in, as the court in Texas found for the plaintiff, which was a physician interest in the state, it really aligned with our case. So we paused our suit and later dropped our suit in favor of supporting the Texas suit, which, as you'll see, follows a line of pushback against the regulatory framework and continues to push back against that framework, so that as one of the issues with this is the court in Texas would solve problems with the regulations. It was kind of whack-a-mole. New problems would emerge. So new suits were filed to take care of that. So we decided to throw our weight behind the Texas suit. But the rest of these, I believe, are not active at this point. The, let's see, how do I go back here? So 18 lawsuits were filed down to really a focal point on Texas. There may be still those happening in the air ambulance area which is really a very separate thing from our case. So ongoing risks. This is really the heart of the whole issue. Which is just the impact that this has had on the practice of medicine for our specialties. But we feel it's, over time, this is gonna have impact throughout medicine. So it's very important to stand up for the integrity of physician contracting and really independent practice. Insurers have used the regulations to undermine existing in-network contracts and drive practices out of network. And we saw this in case after case. We actually have copies of letters that the insurance company would send, Blue Cross in North Carolina, Cigna in Texas, saying, hey, we now have the power to set your rates. We no longer need a contract with you. We're gonna put you out of network. The dispute resolution process requires a significant amount of resources and ties up cash flow while the payment is in dispute. The, first there's the, as Bill alluded to, you know, there's the initial period. There's the 30-day waiting period. There's all this time that data needs to be aggregated. Bills need to be batched. Then it's submitted. It goes through the arbitration process. And then you may, and in most cases, in fact, in the case of anesthesiology, over 90% have been settled for the anesthesiology practice, but the insurance companies have been slow to pay and many documented cases of no pay. So for a smaller practice, there's no way to withstand this. And so we're seeing, you know, practices that have had to lay off people, practices that have had to look for, consolidate with larger groups, really discouraging that whole sense of independent practice. The low qualified payment amounts have negatively impacted practices of all sizes, small, independent, regional practices, leaving them vulnerable and patients. And again, we saw this in, certainly in North Carolina and Tennessee, where there were parts of the state now uncovered for anesthesia care and hospitals had to drop critical services such as maternity in certain areas because of the lack of specialty coverage. And the win rates have been high, which demonstrate that insurers have gamed the system to decrease and delay payment even after arbitration is closed. So you could say it's just a really, you know, negative reaction. So we, even though we paused and eventually dropped our suit because of the fact that the Texas suit was settled in our favor, and you'll see in a little bit about our ongoing support of the Texas suits, we've still remained a viable coalition. And for a number of reasons. First, you know, we've supported the TMA with amicus filings. This coalition has really served a way for us to combine our legal energies, our PR energies, our advocacy energies, executives, our physicians get together, and we really review what's happening, what we're hearing, the evolution of the regulations, what's being experienced on the ground, what these TMA suits mean. And so the combined activity of information flow, but then also action really helps move things along. Our amicus briefs in the Texas case have been cited to help advance those cases in the cause of our members. So it's still collective action. It's still costly action, much less than the lawsuit, but still requires resources, but it has been able to move the ball in support of our members' interests. So that's one. Second thing is we've generated evidence to support our position. And so we continually look at, you know, what data, what we're learning about the environment, and how we can better educate policymakers and the legal system about what's happening. So this study, which the three groups collaborated on to fund and was carried out through Avalere, created the evidence that was needed to demonstrate the use of these so-called ghost rates, sometimes referred to as phantom rates, in the calculation of the QPA. The name of the study was PCP Contracting Practices and Qualified Payment Amount Calculation under the No Surprises Act, and really cites the use of these services that aren't used in primary care contracts, but find themselves into the calculation of the weight. And then, you know, just coordinated messaging and activity throughout. So this is actually pictures on a Zoom call, and you recognize some of the faces up on the podium here. So I love this slide. This is one of the, so it's best, but this really demonstrates 444 in the TMA filings. So this is why Texas has been so important for us as a win, and really shows just how, demonstrates how egregious the rulemaking process has been. And what's really funny about this is with every win, it's kind of whack-a-mole. The agencies are still playing games, trying to retain what they can, or trying to sneak what they can back, peeling the rulings, and really trying to keep the system as close to the regulatory misdesign as they could. But the first ruling came out in TMA 1, October, 2021, which was ruled that the interim rule, was filed October, 2021, which indicates that the interim rule conflicts with the No Surprises Act. The IDR can't default to the QPA as the out-of-network rate. So you would think, all right, hey, we won, but they were still playing games. So the TMA 2, which was filed in September, 2022, says that final rule still gives, it recognized or contested the final rule still gives predominance to the QPA, and the ruling was unfairly advantages insurers. Regulators need to go back to action. Regulators didn't follow, so TMA 3 was filed December, 2022, and really specifically called out the QPA methodology, including the use of ghost rates, and that's where our additional research was heavily helpful. And then we had the anchorman version of this, which was TMA 4, which was filed in January, 23. And that, again, called out the agencies for bypassing the rulemaking process. The interim rules were published and implemented as final rules. It also contested what went into place last winter, which was a seven times increase in the filing fees, in the independent dispute resolution fee. It was $50, went up to $350 overnight, and created a very high batching rule requirement. So that has been, we won that one as well, or we think we're going to win. But anyway, I turn it back to Bill. Thanks, Paul. Yeah, and just again, to go back to the out-of-network versus in-network considerations. Everybody thought this was focused on out-of-network care, but the real impact, the vast majority of the impact, because most, quite frankly, we had data to show that the frequency of out-of-network claims were down in the three, two, and even 1%, depending on the specialty. But the real thing was it gave the insurers the leverage because the qualifying payment amount, if that were the default, then insurers, that's calculated using the median in-network rate. So the insurers are incentivized to just continue to drop that in-network rate down until, quite frankly, it created an access problem. And that was one of the major messages that the physician community and our three specialties were conveying, was you're creating an access problem, as Paul said, because communities are not gonna be supported by these specialties. But we wanted to continue to generate data, and this is just one somewhat specialty-specific slide of what, when they, then this had to do with the rate, the filing rate of $50, it went to $350. So we actually had our health policy institute look at claims filed in emergency rooms, as an example, and found out that 52 to 59% of bundled claims for an IDR would not even recover the $350 entry fee. So who's gonna file an IDR process that's gonna cost them more than they could even claim if they won? And then even when they dropped it to $150, which is where it stands right now, 30 to 44% of the bundles, and we didn't get too much into the batching process, but it would not even rise to that level. So again, it was really important that we had data to back up our arguments with the courts. And to go back to the legal process, the government has elected to appeal two of the Texas Medical Association rulings, and as has been pointed out, our coalition has stayed together to file the amicus briefs in support of contesting those appeals. So let me turn it back over to Sue to wrap it up, and then we'll go to Q&A. Yeah, so I think, you know, Paul had sort of shown that Zoom photo. We've been doing those biweekly calls for three years now. Every Tuesday, four o'clock Central time, five o'clock Eastern time, we get our leaders on the phone, and we get our staff on the phone, and we talk through kind of what's going on. And it was really essential for us, even at the outset, to kind of get that engagement. You know, this is an issue that it was hitting our members. We knew it was gonna hit our members. But there was even still some tension among our specialties because some believe that this is about big business. This isn't about small business. And some believe maybe our members would or wouldn't even understand what this is about. And, you know, how much should we as an organization sort of fight this? And I think, you know, both making sure that as our leadership changed year to year to year, they might not have been around in 2018 when we were initially fighting this battle. A lot of battles going on at the state level. How could we then sort of bring them on board? And so we thought it was really necessary during those calls, which were largely just operational in terms of the work, that we always had our president or our board chair on that call so that they could understand and hear. And in fact, ASA leadership physicians are often the ones running the agenda for that call. And I think that's been really important for them to have that connection and that continuity on that front. In addition to these meetings, we obviously have had ongoing communication and as well, our advocacy folks who much always know each other anyway, right? They're all DC based up here on the hill. But it did keep our comms folks connected maybe in a way that they might not have been before. We were both monitoring what was going on. We were trying our best to try to get some stories in the media that would at least reflect our side of the opinion. And so knowing which reporters were gonna actually take us at face value or which reporters were trying to manipulate our words to put them into a story on the other side was a key part of what we had to kind of think about in our regular ongoing communication. And so it was a really important opportunity for us to sort of stay connected on that front. And this was also really important as the various lawsuits kind of came out as well. The fact that TMA wanted to go this on their own was I think a little bit confusing maybe for some folks early on. The fact that AMA didn't really quite know how to handle the fact that a state chapter was gonna be running this big lawsuit, we weren't really sure as Paul said as to whether or not we could even kind of align and be involved in that. And so I think for us as a group to sort of stay together on that collaborative strategic decision making was really an essential piece that made this make sense. Of course, it doesn't hurt that we shared our resources for this. Filing a lawsuit is a fixed price. Spreading it among three groups definitely makes it a third less. So we really appreciated that and it gave our legal teams chance to really kind of think about how that would work and how that would all fit together. And it really did. I think it solidified so much of the teamwork. Our two legal counsels from different organizations are sitting in the back right there. Our comms people know how to kind of connect together. And so it really did just over time just kind of bridge and build up this teamwork that we had among our staff. And I think it gave us an opportunity to say, you know what, even though we don't really want to sue the government, we do know when there's time that it has to happen. And really thinking about how and when is the right time to take that jump, to leap into that legal space and get into there with our legislative strategy was really important. Now I will say, we also have regulatory teams and those regulatory teams still meet with CMS very regularly to try to guide them through the process. So we were fighting this process. At the same time, we were desperately trying to improve it. We know that this is a hassle. We know that every time one of these TMA rulings would come out, they would just shut down the IDR portal and we would all just sort of sit there with Jeopardy music waiting until they would open up so you could submit claims again. And so trying to help the government even figure out what to do with this has been part of that. But I do worry and I think we all sort of feel there isn't a TMA-5 yet. There isn't even a ACR, ASA, ASAP-2 yet. But there may be a need to do that. I think we're still feeling like, as we said, we got four wins and we're still not there. We really don't know and it still may be time for us to take further legal action. So I think this point, we do wanna kind of open it up to you all. We wanted to make sure there was enough time in this, again, both to have specific questions about this, particularly if you think it is impacting your specialty, but even just to share similar stories if you've got them. And we can keep talking if you don't, but. Absolutely. And I think one key lesson for us is, and seeing more and more of this, is that the legislative feeling is that strategy is kind of deadlocked. It's at best a defensive strategy. And the regulatory system, really not working in our favor, which really is pushing us to legal action on things that are proving very difficult. And we're seeing more suits pop up by different types of physician and provider groups to sort of see where things could be tested. I think with the latest Medicare rules, that may be another place where we may need to consider action going forward. But it's a tough environment and the courts may be a good avenue to advance some of our goals. The only thing I'll add to that, the decision to go legal, as I think has been emphasized, but just to say it one more time, was because we got the law that we wanted. And you don't wanna say, okay, well, let's go back to Congress and have Congress do, because once you reopen that door, you have no idea what's gonna come back out. So never give up ground. If we and all of our organizations believe that we were on good footing, high standing, had the legislation and provisions as we had helped them design, we did not wanna back off and go, just go back to Congress and say, oh, it hasn't been implemented correctly. We had to go directly at the offenders, that is the three agencies that resulted in these rules, this series of rules. Hi. My question actually is, thank you for your great work. I greatly appreciate that. And it's not about my organization, but I'm just curious, and previously, when, well, I had a situation where my child, I was at a hospital, gave birth, the child had to go to the neonative intensive care unit. That neonatal team was not in network, and I got billed $5,000. And ultimately, I worked with them for months, and then we had this health advocate that I don't know what they said, but then two days later, they called and said it was covered. So I'm just curious, in that instance, who actually paid that $4,000? I mean, does it come out of the provider's pocket, or is there some kind of agreement, or was the insurance company just lying? You know, it depends, right? Prior to, one of the things we were seeing as we were ramping up to this is that there were a lot of state laws that were starting to go into place. And I think in some ways, there was almost 20 or so different state laws that would either just ban balanced billing, and say you have to figure it out. Some of them actually had IDR process in it, and were sort of doing that. So it could have been state by state dependent. It certainly could have been just sort of that agreement. And I think, as Bill said, even though it was blown wildly out of proportion that everybody was getting surprise bills of $145,000, it wasn't that big. All the more reason why we said, whatever we do, let's get the patient out of the middle. Let's remove that part of this burden. The cost of health care is tough enough alone. Even if there was an in-network payment, you probably would have spent a lot. And so I think that was kind of that key. So my guess is it might have been some sort of negotiation between the facility and the physician and the insurer. Maybe it was that the facility decided they were going to just do it because it was the right thing to do, or any number of those different things. We certainly do know, and this, obviously, we're here to advocate for our physicians. All of these things colliding, whether it's the deductible or it's the out-of-network payment, these are all being put on the backs of the physician office. And that's why the cash flow and the challenges that we see when you layer in some of these payment disputes on top of it just makes it really untenable for groups. Jackie. Thank you. And I'm Jacqueline Bellow, Chair of the Board of Chancellors at the ACR. And I want to applaud our society leaders and the hard work of this coalition. In doing so, though, I think it's fair to point out that it's not the leaders and the lawyers. The amount of staff, work, and time that this took from the monitoring Tom Dockett's, the court Dockett's, and the monitoring of hearings, and they would coordinate amongst themselves. So if the anesthesia staff couldn't get to that hearing, ACR covered it, or ASAP covered it, and then the whole press side. Because during the whole time, I'm not going to mention any names, but the insurers wanted to just paint the docs as being greedy doctors. So it was to the benefit of everyone to have the PR crews working together on, this isn't about the doctors. Everyone believes the patient should not be in the middle. But once they're out of the middle and they're sick, they need to go somewhere. And if you're closing your doors or you're having to consolidate with another practice and no longer offer XYZ as a result, that patient who's out of the middle is just out of luck. So I just want to applaud not only the strength of the leaders and the lawyers, but our combined staffs and the synergy that took place. Thanks for that remark. And it's really true. I think one of the best features of this was the information sharing that went between the groups. We had a level of intelligence. So previously, before an effort like this, the advocacy team would be working over time to get information, the regulatory team, the PR. But now we're doing it all together. We're faster. We're smarter. We know who to call. It's almost intuitive that they're on the line with each other to try to, what does this rule mean? What did you hear about this meeting over at Ways and Means? All that kind of good stuff has been happening. Yeah, great session, great work. I want to build on the last two comments, actually, because I think part of what's really difficult in an issue like this is how difficult this is to explain to patients. So we've talked a lot about how we've been trying to, at CMS, forge closer alliances with the patient community. I wonder your thoughts about how do you translate an issue like this in a way that the patient community understands that what you're trying to do is not make it worse for them. But actually, as Jackie pointed out, the bad guy here is clear. But I think what we're also hearing is I think those same, the insurers are also going to the patient community and trying to line them up as allies. And I hate when they get caught in the middle of this. But I'd love your reflections of how we kind of work with the patient community, really, because you're absolutely right. My son recently got his finger jammed on a wall. And the number of bills we have received from this urgent care and the radiologist is astounding for a non-broken finger. So this is happening. And patients are still in the middle of it. So I think trying to explain this in a way that feels that a patient can understand what you're trying to do and not feel like they're caught in the middle would be really helpful. I'd love your thoughts. $1,500 for a dog bite this past year. No, I will say that one of the things that was decided very early on, and going back to the communications participation, and all of us had our kind of PR teams in that Zoom call, early on, the first paragraph of every statement that went out was all of our organizations remain fully in support of taking the patients out of the middle and not being subject to, quote, surprise medical bills. And then we would go on in the rest of the statement to describe why we were contesting ghost rates or why we were contesting a seven times increase in the fees or those types of things. But literally every one of those statements, and that was decided early on, was just for what you described. We wanted to be sure that front and center, that the patients knew we were not going to do anything or jeopardize anything about that bill that kept them out of jeopardy. One of the things I think, and this is to the wisdom of what we're working on at CMSS, is to bring the National Health Council to the table and really hear from patient organizations what they understand, how they see the issue, how we could better communicate the issue. Unfortunately, well, there are two things. One, the insurance industry had such a head start in communication. They hid in the background, and for years they pummeled the media with all this information. And probably many of these cases, in fact, these cases were probably largely true, but they're anecdotal cases and not systematic. But what's happening in the background systematically is the insurance industry is consolidating, it's gaining power, and it's really taking advantage of both the physicians and the patients, with the patients, we know, not having access to the services that they need, and physicians really being forced into larger and larger practices, employment arrangements, and really arrangements that they're not happy with. So at the end of the day, I think the process is making things worse for patients. But we've had our public relations teams get together, and at least with what we have so far, it's very hard to get a messaging that really can set that narrative right. So I think really having these conversations with the patient community can really help. And I think, too, it's now been long enough, and we're still fighting enough, that it's a little easier to get some of that media attention. Because now we're saying things like, they're still not getting paid. They win, and they're still not getting paid. The prices are outrageous. It is closing practices. One of the insurance tactics right away was this beautiful brochure that said, we've fought for this for you, and we're going to put this money back into your employers' pockets because we've negotiated this. I don't know about you, but who saw their insurance rates go down this year? I mean, it's not happening. And so I think that we do need to stay in this evidence generation. Even if this was working, I think we would stay there, too. The law had built in it some assessment over time. We know those haven't even happened yet, too. And I think there will just be continuous, continuous things we need to come back to the table on with evidence to kind of look at it. And we very intentionally call it disinformation. This is a disinformation campaign on the part of the insurers to say that this is something that it's not. I'll just make one other comment with regards to the kind of final result. We can win all the court cases, but the bottom line is if the insurers are still holding the money, or CMS closes down the IDR process, the care has been delivered, and the practices are out, the value of that care, whatever it be determined to be. So as I say, they're holding the time wand in their hand, unfortunately. And that continues to be a real challenge. And creating more out-of-network care. Yeah. Tom? Oh, I'm sorry. First, thank you for a really great presentation and a really interesting approach to resolving the issue. I wanted to ask if you think this same sort of process or thinking or collaborative approach could be used to address other issues? And myself, personally, I'm thinking specifically of the current legal landscape as it relates to DEI programming. That's a good one. I mean, I do think, I certainly know that the model can work. Even when we were doing some of the research, we were doing some data collection, we were very careful to make sure that we weren't now running afoul of looking like we were rate setting, like we were colluding in any way, shape, or form to look at what was happening. So we had to be incredibly mindful of this position we had as organizations to do that. And that did just sort of help us think through what we can and can't do in terms of data collection. But I do think, I mean, we certainly have been seeing, I think any of our legal counsels would probably speak up about this, more and more opportunities for us to get involved in, if not direct legal action, certainly amicus briefs. I know our organization has, I think we put out 12 different amicus briefs this past year, which is a year and a half. And that's just astronomical for us. So I think we are getting a little bit more comfortable about being able to sort of say we have a place in this. And I think we should be proud of that. In places where we could stay together on this collective action, there were two legal issues this year that came in front of the CMSS community where we collaborated on the amicus briefs. And they really did have a lot of power. One was one which IDSA, the infectious disease group, was appealing a ruling that would have put our whole standards process at jeopardy. And we were able to stand together on that one. And another one was where our society, ASA, was sued by a pharmaceutical manufacturer for what they felt was trade libel in our journal. We were able to stand together on that. The amicus brief was very helpful in getting that case dismissed. So I think these are, I think, not only important strategies, I think they're going to be an essential part of the arsenal of advocacy for all our organizations. I agree. It was a really interesting presentation. And I congratulate you on pulling yourselves together. I was going to get to a similar question, but I was going to back into it by first asking a question related to this particular instance. There's a book that was published about 50 years ago called The Logic of the Collection of Action. When costs and benefits are concentrated, the collective action is more likely. And as the groups get larger, you have the free rider problem. That is people who might benefit but don't have to put anything into it tend to stay on the sidelines. So in particular, in the case of this effort, I understand why you guys were brought together on it. But there were other disciplines that are affected by it. Regina's question about the pediatric ICU is that pediatric groups are often organized in negotiating different kinds of contracts with the hospitals. And we had similar experience with pediatric care. So I guess I'm wondering, once you got started, and then I was also surprised to a certain degree that you have a partner in the TMA. There's a big divide between the specialty societies and the Federation of Medicine in a way. And yet, you're in different boats but pulling in the same direction. How much coordination was there across that divide with the medical society? And then were there other societies that were sort of sitting on the sidelines that were thinking about joining you but decided not to join you? I want to get to the bigger question, though, of the larger threats to the profession after you answer that question, because I am just curious. We didn't tally up the number of amicus briefs in support of all of the various lawsuits. We certainly know we supported amicus briefs in the TMA, but many, many other groups did as well. So there were some from state societies who joined in as amicus briefs as well. There were some our practice management group, trade group that runs our practices, was very actively part of that. I think yours was as well. I think that there was a place when we said, we're winning. And Texas was picked on purpose for that. Do we take a chance at a loss? And so that's when you sort of say, you know what? Let's keep the winning going and let's put these other lawsuits on hold. And so there was a little bit of that coordination of who's going to speak up when and where and that sort of thing. One of the issues with the AMA was that there was already this other lawsuit in DC. We did not file in DC because we didn't want to risk being combined with somebody else's case. The air ambulance case was a little different. We really didn't want to get kind of lumped into that. So there was definitely some strategy around where, when, and how and various parts of that. The other thing I'll add is I think we wanted to remain relatively nimble because we thought this was likely to be somewhat of a moving target, which turned out to be true. And as you expand to more and more groups, you can imagine that Zoom call with four or five times that many faces on it trying to get anything done. And the other challenge, I think that this was not a political process. It was a judicial process. When you get into a political process, yeah, I'm going to, just like the coalition that's been created as far as mitigating CMS cuts, over 100 organizations, physicians and non-physician organizations, then you need the bulk to have the clout. We felt pretty strongly that we were on solid footing from a legal basis and so that adding more voices wouldn't necessarily be an advantage and might be a hindrance. And I was going to say, with regard to the Texas Medical Association, there was a behind-the-scenes flow of information between members there as well as their legal counsel. So we knew what was coming up. They wanted to go their own way. They didn't want extra weight on their suit. But we knew that they were going to be aligned with our interests. And there was a flow of information. An anesthesiologist at the time was president of the TMA and good connection with our issues. So there was an active ear to what was going on. And the final thing I'll mention is, had the Texas case not gone in the direct for the physicians, we wanted to have the other suits still active to look for a favorable ruling in another federal jurisdiction. I'm sorry, your second question, Tom. This is very interesting, because it does reflect that you have different kinds of strategies for different kinds of problems. The larger question in my mind relates to the previous question, which has to do with the larger threats to the profession. We saw so much legislation in the past year interfering with the setting of standards, the enforcement of standards, the enforcement of all these new contents laws, which are violating ethical guidance from the societies. And it's a real threat. I think it's a real threat to the profession. But it's really hard to get the profession together to address them. And I don't know what you think the prospects are for that kind of organizing around that kind of threat, which is, I think, actually quite generalized across the specialties. I think it's not directly an answer to your question. But I know for us, we have said, we've got to focus at the state level. So many of these battles really happen at the state level. And so we need to ensure that our states are kind of prepared to be able to do this. And we are looking to sort of see where we kind of intervene and where we can add our clout to what's happened in that state. So I know that is one way to think about it and that kind of alliance and allegiance, particularly with some of these what I would just put together largely as physician autonomy challenges that I think are really kind of facing us. But as Paul said, I think that where we stand with congressional action or legislative action on anything pertaining to broad payment of physicians, it's time for us to think about, is there a different attack, a different approach to this? And I think this has shown us we can work both the regulatory and the legislative angle. And if we need to take legal action on the legislative, not following through with the regulatory, then we need to do it. Yeah, no, I agree. It's got to become part of our arsenal, our strategy of thinking. One thing that we've been, as medicine, we've been very good at fighting with each other, spending a lot of our energies against each other. And I think that's one of the things through this kind of collective strategy, I think we can make a difference. And the more we can come together, I think the more power we will have in these settings. And Tom, another, I'm not sure that this is what you asked, but part of the legal strategy is what district, what court we could be most successful in. And we found that Texas found a judge who was sympathetic to our cause. And I think that in every case that we've looked at, and when we've looked at filing, when we look at the history of that particular court and the kind of decisions they've made. And it was close enough that Leslie could take a road trip and listen to the one rule, which was a lot of fun. This is our legal staff in the back, Leslie Moore and Tom Hoffman from ACR, that's with me. And Jeremy Lewin, who was around here several other days, just not today. Yeah, Jeremy. He's with the ASA, so. He's trying to stay one step ahead of the law. So he's. Yeah. But no, this is fine. It was just to, I think hopefully to stimulate conversation and at least from my perspective, these are existential challenges to the way we've known medicine, to the way medicines practice, to the autonomy of physicians, to the ethical basis of the specialty. So having this type of action in our toolkit is really, I think, very important. And I think the one piece you didn't really hear us say, but obviously it was happening in the midst of this, is that this all occurred during COVID. The last ramp up of all of this occurred when all of our physicians were at their very end of what they were trying to deal with in that first year of COVID, and then for this to come out. And I do think that that had something to do with our desire to say enough. We can't pile this on. We just can't pile this on. My last comment would be, I think our members, and I respect all of your members, think of advocacy in a legislative sense. And they don't really realize what your organizations do at CPT or at the RUC or in a legislative way as advocacy as well. And I think it's really important that we continue to message to them that there's a broad spectrum of ways that our organizations are advocating on their behalf. I think those were our concluding remarks, right? And find partners you'd like to work with. And we're available. Thanks so much. Thank you.

panel discussion

No Surprises Act

surprise medical bills

insurance industry

healthcare providers

legal action

Texas Medical Association

patient community

collaboration

physicians' autonomy