There is considerable debate across health care, and certainly within the specialty of anesthesiology, about the merits and drawbacks of various ownership structures. I’ve been involved in countless discussions on the topic over the last few years, and the one common thread I see in these encounters is frustration. The conversations almost never leave anyone happy. But there is one constituency that is very happy to have us debating ownership structures because it takes our eye off them, our true adversary at the moment: commercial insurers. They’d rather have the house of medicine, anesthesiology included, focused inward rather than unifying against them.
Commercial insurers employ a lot of smart, very well-connected people. They make billions in profit by paying out as little as possible, and they exert enormous influence over anesthesiologists’ professional lives. Among their tactics:
Unilateral contract termination or non-renewal: Insurers have unilaterally terminated contracts with anesthesiology groups to force them into “take it or leave it” positions of accepting lower payment rates. They have refused to renew contracts. Often, they take these actions with little notice. This leaves practices scrambling to negotiate new terms or face the possibility of being pushed out of network, a key commercial insurance strategy since the botched implementation of the No Surprises Act (NSA).
Low-ball payment rates: Anesthesia services have long been undervalued, but insurers continue to try to push rates even lower. We see this in the elimination by some commercial insurers of payment for ASA Physical Status Classification status and some qualifying circumstances. More recently, insurers have started manipulating payments for anesthesia time. Often, rates for anesthesia services barely cover the cost of providing care and provide no room for investments in patient safety and technology initiatives. These low rates also fail to account for the specialized training and critical nature of anesthesia care, leaving practices unable to sustain themselves financially.
| Submitted a formal complaint to the U.S. Department of Justice (DOJ) regarding the potentially anticompetitive behavior of UnitedHealth Group and Optum. In 2024, it was announced that the DOJ had launched an investigation. |
| Filed a lawsuit and multiple joint amicus briefs with the American College of Emergency Physicians (ACEP) and American College of Radiology (ACR) in support of the Texas Medical Association’s successful NSA lawsuits. The favorable court rulings forced the federal government to retreat from pro-insurer provisions of the NSA’s implementing regulations and strengthened physicians’ position in their negotiations with insurers. |
| Pushed the Center for Consumer Information and Insurance Oversight (CCIIO), the agency responsible for implementing the NSA, to lower the administrative fee for the submission of claims to the IDR process, reducing an obstacle to physicians wishing to challenge unreasonably low payments. |
| Partnered with ASA state societies to battle unilateral payment policy changes by payers. These joint effortsresulted in the reversal of a harmful proposal to cease payments for anesthesia for colonoscopies in Massachusetts. Current battles are underway to halt commercial insurer proposals to stop payments for physician status modifiers, qualifying circumstances, and for nonsensical changes to how insurers approach anesthesia time. |
| Lobbied the U.S. Department of Health and Human Services to hold UnitedHealth Group and Change Healthcare accountable for their failure to properly manage the cyberattack on their system and to make physician practices whole for delayed payments. |
| Joined with ACEP and ACR to push HHS to shut down insurers’ greedy “shared savings” programs. |
| Supported the finalization of federal regulations that, once fully implemented, will rein in abusive Medicare Advantage prior authorization practices. |
Gaming the NSA: After the passage of the NSA, insurers were ready. They devised ways to manipulate the law’s Independent Dispute Resolution (IDR) process, flooding the system with low-ball, rigged offers based on the Qualifying Payment Amount, betting that smaller practices would be unable to withstand the lengthy and expensive dispute process and would be forced to accept unfavorable terms. By overwhelming the system, insurers tipped the scales in their favor, knowing that practices can’t afford to spend the time or money needed to dispute every claim. More disconcertingly, anesthesiologists have frequently encountered delays in payments from insurers. Even when services are billed correctly and the anesthesiologist prevails in the IDR process, insurers are often slow in processing claims. Worse still, insurers sometimes deny legitimate claims, cite minor technicalities, or request unnecessary documentation, all in an attempt to avoid or delay paying for services rendered.
“Look for more from ASA this year. We will use all the mechanisms at our disposal to demand fair payments, push for regulatory reforms that hold insurers accountable, and engage in advocacy to protect patient access to anesthesiologist-delivered and anesthesiologist-led care.”
“Shared Savings” schemes: Insurance companies have devised proprietary arrangements to obtain generous fees for slashing payments to frontline health care professionals. One insurer reaped an “annual windfall of about $1 billion in fees” according to a groundbreaking New York Times exposé in April 2024. “The formula for Multiplan and the insurance companies is simple: The smaller the reimbursement, the larger the fee,” the report said.
Refusal to recognize anesthesiology as essential: Insurers have attempted to sidestep their payment obligations by arguing that anesthesia services are not essential or that they should be bundled into the overall cost of a surgical or procedural episode. This fails to acknowledge the crucial role anesthesiologists play in patient safety and high-quality outcomes. In extreme cases, insurers have denied coverage for anesthesia in procedures they claim could be performed without it, despite clear evidence to the contrary.
These tactics have dire consequences for anesthesiology groups of all sizes and types, but small- and medium-sized independently managed practices are hit especially hard. With limited negotiating power compared to larger groups or health systems, independent practices often find it more difficult to secure fair reimbursement rates in negotiations with commercial insurers. We can draw a straight line from the financial pressure created by insurer tactics to the practice consolidation and sales to larger entities over the last decade.
Commercial insurers have gone on the offensive. No matter your practices’ ownership structure, anesthesiologists share a common struggle against insurer-driven financial challenges. Over the last few years, with the engagement of our members and groups, ASA has strengthened its resources and taken on “big insurance.” Our initiatives have included the actions listed in the Table.
Look for more from ASA this year. We will use all the mechanisms at our disposal to demand fair payments, push for regulatory reforms that hold insurers accountable, and engage in advocacy to protect patient access to anesthesiologist-delivered and anesthesiologist-led care. By focusing efforts on confronting the challenges posed by insurers, with ASA as the convener, we can ensure that anesthesiologists continue to provide the high level of care their patients deserve and be appropriately compensated for doing so.