Beyond the No Surprises Act: What Real Patient Protection Looks Like

How Free-Market Health Plans Address Posted Prices, Surprise Bills, and PPO Price Gouging

A recent article from KFF Health News confirms what many of us in the industry have seen: the No Surprises Act (NSA), though well-meaning, isn’t protecting patients the way it intended. Despite all the noise, Americans are still cold cocked with massive medical bills, many for services they never agreed to or providers they never selected.

Patients are getting hit with charges from assistant surgeons they never met, emergency room doctors they didn’t choose, and labs or anesthesiologists quietly billing as “out-of-network” even though care was delivered at a supposedly in-network facility.

The NSA was supposed to end this. It promised balance billing protection, price transparency, and advance cost disclosures. But like most federal fixes in healthcare, it arrived tangled in bureaucracy and riddled with loopholes.

Here are just a few of the ongoing issues with the NSA:

• The “good faith estimate” rule doesn’t apply to people with insurance. Under 42 U.S.C. § 300gg-136, uninsured patients are entitled to a Good Faith Estimate (GFE) and can dispute final bills that exceed it by $400 or more. Insured patients, however (those on traditional plans) are excluded. HHS has postponed the “Advanced EOB” that would’ve extended this protection, leaving most Americans in the dark when it comes to knowing what care will cost. If the patient is insured and intends to use their coverage, the provider must send the GFE to the insurance plan, not the patient. If the patient is uninsured or not using insurance, the provider must give the GFE directly to the patient.
• Ground ambulances are completely exempt. You can call 911 and get a $3,000 out-of-network bill, with no NSA protection at all.
• Providers are gaming the rules. Examples include: ER visits are reclassified as non-emergent after the fact. Facilities bill as “participating” but route claims through out-of-network physician groups. Post-stabilization care is misrepresented to appear as though the patient consented to it. Assistant surgeons, anesthesiologists, and pathologists bill independently, hoping to fall through the cracks.
• Enforcement is weak, and the appeals process is onerous. Even when the law applies, patients rarely know their rights, let alone how to assert them.
• Surprise bills still occur daily. Nothing has fundamentally changed. Patients are still the payer of last resort, and most only realize they’ve been overcharged once they receive a collections notice.

We Saw This Coming and Built Something Better

While Congress debated how to protect patients, we went ahead and did it.

At The Mahoney Group, we’ve been building free market health plans that bypass all of this nonsense by flipping the entire model on its head. These plans aren’t patchwork fixes to broken PPOs. They are designed, from the ground up, to give members clarity, access, control, and protection.

Here’s how:

• Direct Primary Care (DPC), where geographically available, often becomes the anchor. Members get unlimited access to a trusted primary care doctor without deductibles, copays, or billing surprises. This alone resolves the lion’s share of care navigation and deflects countless unnecessary referrals and emergency room visits. I have a video on four ways to use DPC, here.
• Cash Payment Options are readily available from like-minded free market providers. Whether it’s labs, imaging, or elective surgery, members can choose to pay a clear, pre-negotiated price, often at about half of of a PPO’s cost (about 130% to 150% of Medicare). If a facility posts a lower price than what our RBP engine would reimburse, we can use the cash pay route. I wrote about one example of that here in One Mom’s Nose for Savings.
• Open Access Plans mean there’s no network trap. Members can see any provider they want. There’s no “in-network ER” only to find out the radiologist wasn’t in the same network. There’s no third-party database dictating what doctor you’re allowed to trust.
• Transparent PBMs are a critical part of the stack. We ditch the rebate games, mystery formularies, and pharmacy spread-pricing tactics. Our PBMs contract in clear terms, share 100% of rebates with the plan sponsor, and disclose every margin. We write this into our PBM contracts with teeth. Check out my recent podcast with Disclosed Rx’s CEO and cofounder, Zack Robinson.
• Reference-Based Pricing (RBP) serves as the legal and financial titanium reinforced backbone. Providers are reimbursed based on a fair multiple of Medicare or a percentage markup on their self-reported costs, whichever is higher. We don’t pay claims based on imaginary PPO “discounts.” This makes our pricing predictable, consistent, and legally defensible across the board.

The Real Differentiator? We Never Abandon the Patient

Here’s the part most plans never talk about. 

We’ve paired this innovative front-end structure with a concierge claims support system and a real legal infrastructure that follows every claim to the end. When a provider tries to balance bill or push back, the member doesn’t go it alone. Our team of advocates and attorneys step in.

• We negotiate directly with the provider.
• We challenge inaccurate codes, duplicate billing, or inflated charges.
• We defend the reimbursement amount, up to and including legal proceedings when necessary. Podcast with Attorney Amy Pellegrin on the legality of RBP.
• We educate the provider on the plan design and stop them from manipulating patients.

Now, if a patient knowingly and willingly chooses a higher-cost provider after reviewing their options, we let them. That’s the beauty of free market healthcare. If someone wants to see the most expensive spine surgeon in New York and knows there may be a balance to pay, that’s their decision. We do our best to negotiate a reasonable price (which is often, in that case, identical to what a national PPO would pay), and we show them other quality options, often at half the price, but it is their choice. 

And No, Cash Prices Alone Don’t Fix This

Some argue that reference-based pricing is obsolete now that hospitals are posting cash prices. That argument is like saying we don’t need highway patrol anymore because speed limit signs exist.

Yes, prices are posted. But is anyone enforcing them? Are they honored? Are they fair? Is the patient protected?

Hospitals and insurers continue to prove they’ll do whatever it takes to preserve inflated billing, NSA or not. We've seen ER doctors bill at 900% of Medicare while claiming compliance. We’ve seen “cash rates” posted at $4,000 for a procedure that costs $400 across town. Posting a price doesn’t mean you’re charging it fairly, or that you won’t use fine print to claw back the difference.

Reference-based pricing remains the essential enforcement mechanism, especially when we use a two-pronged reference, paying the greater of Medicare plus a percentage or a facility’s self-reported cost plus a percentage. And when it’s combined with direct primary care, cash pay navigation, open access, and transparent PBMs, it becomes an entire ecosystem that delivers on real, legal, ironclad patient protection. 

Final Word

While regulators hold press conferences about the next wave of fixes to a broken model, our clients are getting real results.

• Surprise bills are resolved.
• Members are protected and empowered.
• Employers are cutting costs by 25% to 30% while guarding access to quality, reasonable providers. 

Our free market plans don’t ask patients to read the NSA, understand ERISA, or negotiate with hospital billing departments. We do that for them. We work with them to provide access on the front end, protection on the back end, and everything in between.

If you’re still stuck inside the PPO hamster wheel, hoping network discounts and government mandates will protect your people, it’s time to try something different.

Our clients already have. And they’re not looking back. I’ve still yet to have a client leave RBP once they’ve opted for that path. The truths uncovered and the savings seen are too powerful to ever warrant backsliding into the insured abyss.