Keep attacking doctors: What the New York Times gets wrong about surprise medical bills

Surprise medical bills are the healthcare equivalent of stepping on a Lego in the dark: you didn’t agree to it, you didn’t see it coming,
and somehow you’re the one paying for everyone else’s bad decisions. So when big outlets cover the topic, you’d hope they’d aim their
flashlight at the real causesnetwork design, contracting games, market power, and a billing system that treats patients like forwarding
addresses.

Instead, a familiar storyline pops up: doctors are the villains, surprise billing is their hustle, and the fix is to rein them in. It’s a
satisfying narrativesimple, emotional, and easy to share. It’s also incomplete. And when coverage is incomplete, policy gets messy, trust
gets worse, and patients keep getting those “wait… what is this charge?” envelopes.

Let’s talk about what gets missed, why it matters, and how surprise billing actually works nowespecially after the federal No Surprises Act.
We’ll keep it plain-English, with just enough humor to keep your blood pressure from needing a prior authorization.

What counts as a “surprise medical bill,” really?

A surprise medical bill usually happens when you do the responsible thinggo to an in-network hospital, use your insurance card, avoid
random sketchy clinicsand still get billed as if you hired a celebrity surgeon on a yacht.

The classic setups

• Emergency care: You go to the nearest ER. The hospital may be in-network, but an emergency physician group, radiologist, or
  specialist involved in your care may be out-of-network.
• Hospital-based specialists: You schedule surgery at an in-network facility, but anesthesia, radiology, pathology, neonatology,
  or other “behind-the-scenes” clinicians may not be contracted with your plan.
• Air ambulance: Not exactly a service you comparison-shop for while hovering at 10,000 feet.

The key point: patients often can’t meaningfully choose which clinician shows up on the claim, especially in emergencies or
facility-based care. Blaming patients is unfair. But blaming “doctors” as a single group is also too blunt. “Doctor” here can mean:
an independent clinician, a hospital-employed physician, or a private-equity-backed staffing company using doctors’ labor like a billing
instrument. Those are not the same thing.

The New York Times framing: why it feels true

Media coverage often highlights extreme bills (because they’re real and awful), then connects them to out-of-network physician charges,
sometimes implying that physicians collectively engineered the system. You can’t blame journalists for wanting a human face on a complex
policy story. But the face they choose shapes who the public thinks “did this.”

A common theme in the 2019–2020 era was that doctors, hospitals, and insurers were all “basically fine” with the status quo because it made
money for everyone. Sometimes that’s written as a three-way tug-of-war; sometimes it reads like a three-way conspiracy. The difference matters.
One is a market problem with bad incentives; the other implies moral failure by clinicians who are, in many cases, not the ones holding the
contracting pen.

What gets wrong (or at least oversimplified)

1) It treats “doctors” like the decision-makers in a system they often don’t control

Many surprise billing headlines come from specialties that work inside hospitalsemergency medicine, anesthesia, radiology, pathology,
neonatology. In lots of communities, those services are staffed via contracts negotiated by hospitals or staffing firms, not by individual
physicians. A clinician can be the name on the bill without being the architect of the billing strategy.

In other words: the person you picture (your family doctor in sensible shoes) is not necessarily the entity negotiating network status, fee
schedules, and legal strategy. Sometimes it’s a corporate group that happens to employ doctors.

2) It ignores the role of insurer network design (a.k.a. “narrow networks with a straight face”)

Surprise bills flourish when networks are thin, outdated, or constructed to look affordable on paper while limiting contracted rates in practice.
If a plan keeps facility networks broad but lets professional networks stay narrow, patients get the illusion of coverage with the reality of
out-of-network claims.

That’s not “patients didn’t do their homework.” That’s “the homework was written in disappearing ink.”

3) It confuses sticker prices, negotiated rates, and what anyone actually pays

Chargemaster prices (the list prices hospitals and some groups put on bills) can be wildly detached from negotiated rates. A story that leads
with a giant billed amount can unintentionally imply that the full amount is collectible in the real world. Sometimes it is pressured down by
negotiation, plan rules, or legal protections. Sometimes it isn’t. But treating the sticker price as the “price of care” is like treating the
MSRP on a car as what everyone pays, everywhere, forever.

4) It downplays hospital leverage and facility contracting games

Hospitals have their own incentives. They may grant exclusive contracts to specialist groups. They may benefit from staffing arrangements that
keep services covered while shifting friction to the billing layer. And they can charge facility fees that patients never anticipated, even when
the physician bill seems reasonable.

If a story focuses only on physician billing behavior, it risks missing the bigger negotiating battlefield: hospitals versus insurers, often with
patients caught between them.

5) It lumps predatory behavior and ordinary billing disputes into one moral category

Yes, there wereand still arebad actors. Some corporate groups used out-of-network billing as a business model, especially in high-leverage
settings like emergency departments. But there are also legitimate disputes about underpayment and contract terms, where the “surprise” is less
about greed and more about a plan paying a rate that clinicians argue is artificially low.

If coverage treats every dispute as a shakedown, it becomes harder to design fair solutions. A system can punish predatory strategies without
pretending all clinicians are running the same playbook.

What the No Surprises Act changed (and what it didn’t)

The best news in this entire topic is that federal law now shields many patients from the worst of surprise billing. The No Surprises Act
generally prevents patients from being balance billed for:

• Out-of-network emergency services (including many post-stabilization situations until certain conditions are met).
• Out-of-network non-emergency services delivered at in-network facilities when the patient didn’t consent.
• Out-of-network air ambulance services (with important details and ongoing policy complexity).

Instead of the patient paying the out-of-network difference, the patient typically owes only what they would owe in-network (deductible,
copay, coinsurance). Then the provider and the plan fight it out in the grown-up room.

The part people miss: the law moved the fight, it didn’t erase it

The No Surprises Act didn’t magically make prices fair. It changed who bears the risk of disagreement. Patients are pulled out of the
crossfire, and payment disputes move into a formal process between plans and providers.

That’s a win for consumers. But it also means the policy spotlight shifts from “the patient got a bill” to “the system is arguing about what
the bill should have been,” which is less emotionally viral and more administratively terrifying.

The messy middle: IDR arbitration and the QPA (where everyone becomes an amateur economist)

When a plan and provider can’t agree on payment for a protected out-of-network service, they can go through the
Independent Dispute Resolution (IDR) processoften described as “baseball-style arbitration.” Each side submits an offer; the
arbitrator picks one.

What’s the QPA?

The Qualifying Payment Amount (QPA) is basically a benchmark built from the plan’s median in-network rate for a service in a
geographic area, adjusted in specific ways. It affects patient cost-sharing and is a major reference point in arbitration.

Here’s the problem: both sides accuse the other of gaming it.

• Providers’ complaint: insurers calculate QPAs in ways that push them down, making “fair payment” look smaller than it should.
• Insurers’ complaint: some provider groups flood IDR with disputes, win frequently, and drive payments above in-network levels,
  which can raise premiums.

Meanwhile, the government has had to manage huge dispute volumes, a backlog, and ongoing litigation over parts of the implementing rules.
This is where simplistic “just cap it” takes run into real-world complexity: cap what, exactly, and based on whose data?

What the early evidence suggests

Public analyses of IDR outcomes have found that awards can be significantly higher than Medicare rates and often higher than the QPA, with
considerable variation by specialty and service type. That doesn’t automatically prove “doctors are winning unfairly” or “insurers are cheating.”
It proves the market is still dysfunctionaljust with better patient shielding than before.

So who’s actually responsible for surprise billing?

If you’re looking for a single villain, you’re going to be disappointed. The surprise billing era was built from misaligned incentives
across multiple powerful players:

Insurers

• Design networks and decide who gets contracted.
• Control payment policies, denials, and claim processing rules.
• Can create “coverage gaps” that patients can’t see until after the fact.

Hospitals and health systems

• Negotiate facility contracts and decide staffing models.
• May outsource key departments to groups with separate contracting strategies.
• Charge facility fees and control the site-of-care choices available to patients.

Physician groups and staffing companies

• Some used out-of-network billing as leverage in negotiations.
• Some are owned or influenced by private equity with aggressive revenue targets.
• Some clinicians inside these groups have little say over contracting decisions.

If a story blames only “doctors,” it risks missing how often surprise billing was a symptom of market power plus opacitynot a
personality flaw in your anesthesiologist.

What patients should do if a “surprise bill” shows up anyway

Even with protections, weird bills still happen. Sometimes it’s a billing error. Sometimes it’s a service not covered by the law. Sometimes it’s
a plan processing problem. Here’s a practical approach:

1. Don’t panic-pay immediately. Check whether it’s a bill, an estimate, or an Explanation of Benefits (EOB).
2. Confirm the setting: Was it emergency care? Was the facility in-network? Was it air ambulance?
   Those details matter for protections.
3. Call your insurer and ask: “Was this processed under the No Surprises Act protections?”
   Write down dates, names, and reference numbers.
4. Call the provider billing office: Ask if they can re-bill correctly or place the account on hold while the claim is reviewed.
5. File a complaint if needed: If you believe the bill violates federal protections, complaints can be filed through the appropriate
   channels (federal or state depending on your plan type and situation).

This isn’t about “getting out of paying.” It’s about paying what the law says you oweand no more.

A better way to talk about it (and a better way to fix it)

The most useful question isn’t “Which profession should we shame today?” It’s:
How do we prevent patients from being trapped between contracts they never signed?

Better narratives

• Treat surprise billing as a system design failure, not a morality play.
• Separate bad-faith business models from ordinary disputes about fair reimbursement.
• Talk openly about market concentrationon the insurer side and the hospital sideand how it shapes prices.

Better fixes

• Network adequacy and accuracy: if plans sell “in-network,” networks should be real, current, and usable.
• Transparency with guardrails: more price visibility helps, but only if patients aren’t punished for information they can’t access.
• Cleaner arbitration rules: reduce gaming, speed up processing, and improve data integrity around QPA calculations.
• Accountability for corporate actors: especially where staffing companies or intermediaries drive volume and strategy.

The No Surprises Act was a big step. But the continued fighting over arbitration outcomes is a reminder that you can’t legislate trust into a
market that’s still opaque and concentrated. You have to build it.

Conclusion

Surprise medical bills were never just about “doctors sending big bills.” They were the predictable outcome of a fragmented system where
patients can’t choose key clinicians, insurers can shape networks to their advantage, hospitals can outsource essential services, and corporate
owners can turn billing friction into profit.

The New York Times (and plenty of other coverage) often captures the pain but misses the plumbing. If we want fewer surprise billsand less
surprise angerour analysis has to match the real complexity of who controls contracting, data, and leverage.

Protect patients first. Then fix the incentives. And maybe, just maybe, stop treating every clinician like they personally invented the CPT code.

Experiences from the real world (what this looks like up close)

To understand why the “blame doctors” storyline doesn’t fully work, it helps to look at what the surprise-billing era (and the post–No Surprises
Act era) feels like for the people living inside it. These are composite experiences based on common patterns patients, clinicians, and billing
staff describenot a single person’s diary entry.

A patient who did everything “right”

A patient schedules a procedure at an in-network hospital. They confirm the facility is covered, they pay attention to their deductible, and they
even ask for an estimate. The surgery goes fine. Weeks later, a separate bill arrives from anesthesia or pathology marked “out-of-network,” and
the number looks like it was generated by spinning a roulette wheel.

The patient calls the hospital and hears, “That’s a separate physician group.” They call the physician group and hear, “Your plan doesn’t
contract with us.” They call the insurer and hear, “We pay a reasonable amount; they’re billing above it.” No one says, “You’re rightthis was
unavoidable for you.” Everyone says, “Talk to the other guy.”

This is the emotional core of surprise billing: the feeling of being penalized for a choice you never got to make.

A clinician who can’t control the contract but wears the blame

An emergency physician finishes a twelve-hour shift. They’ve had three truly sick patients, a handful of scary near-misses, and a waiting room
that never empties. They go home and see a social media thread about “ER doctors ripping people off with surprise bills.”

The physician knows the billing entity is often not the individual doctor. In many markets, it’s a contracted group (sometimes owned by outside
investors) negotiating with insurers. The doctor’s leverage is mostly clinical, not contractual. Yet when a patient is angry, the anger lands on
the doctor’s professionbecause that’s the name the patient recognizes.

That mismatchbetween who appears on the bill and who controls the dealcreates lasting distrust. And distrust makes everything harder:
following discharge instructions, accepting medical advice, and even believing that care decisions are about health rather than revenue.

A billing office caught between law, coding, and chaos

Billing staff often live in the unglamorous space between “what happened clinically” and “what the claim system will accept.” After the No
Surprises Act, they’ve had to learn new rules, new notices, new timelines, and new ways claims can be rejected. Many are trying to comply.
Some are overwhelmed.

When a claim should be protected under federal rules but gets processed incorrectly, it can generate an inappropriate patient bill. Fixing it may
require reprocessing, resubmission, or escalation through plan channels that move at the speed of a fax machine running on vibes.

Patients sometimes interpret delay as indifference. Staff often experience it as bureaucracy. Neither side feels respected, and both sides are
exhausted.

An insurer’s “reasonable payment” versus a provider’s “non-viable rate”

In the post-law world, the dispute often shifts to what the plan should pay the provider. Plans point to the QPA and say, “We’re paying the
benchmark.” Providers look at that benchmark and ask, “Benchmark based on what, exactlyand whose data?”

In some specialties, clinicians argue the benchmark undervalues the complexity of the service or the local cost structure. Plans argue that if
arbitration awards climb too high, premiums rise and networks destabilize. Both can be partly true. And because the IDR process selects one of
two offers, both sides have incentives to position aggressively.

The “fix” that accidentally becomes a new problem

Some patients notice that even after protections, they still receive confusing billsespecially around estimates, scheduling, and facility fees.
One person might be protected from balance billing for the physician portion but shocked by a facility charge. Another might receive an estimate
that turns out to be incomplete because the care pathway changed midstream. Another might face delays where the bill arrives months later, when
they’ve already lost the paperwork and the emotional energy to fight it.

That’s why focusing only on “surprise billing equals out-of-network doctors” can be misleading. The deeper experience is “I can’t predict the
financial consequences of getting care,” which is a system-wide problem. Fixing one part helpsbut the patient experience only improves fully
when the rest of the billing ecosystem becomes legible, timely, and enforceable.

The takeaway from these experiences is not “doctors are always right” or “insurers are always wrong.” It’s that the old surprise-billing mess was
engineered by contracts and incentivesand the cleanup requires contracts and incentives to change, too. Patients deserve protections that work
automatically, without requiring them to become part-time claims investigators with a minor in hold music.