Independent Physician 🇺🇸 • Bring Back Private Practice! • Minimally Invasive Spinal Surgeon • Disc Replacement • Endoscopic
New York, USA
Joined December 2017
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Dan Choi, MD, FAAOS retweeted
When Dr. Will Flannery (@DGlaucomflecken) had a cardiac arrest during COVID, he received a $20,000 surprise bill form out-of-network physicians at the in-network hospital where he was taken. On the latest Knock Knock Hi podcast, he explains why the No Surprises Act matters and why insurers are now lobbying to change it.
His key points line up with the data:
1. Patients are protected. The law took them out of the middle and arbitration only decides what the insurer owes to the physician
2. Physicians win most disputes because independent arbitrators, choosing between two offers, keep finding that the insurer’s number is too low
3. Insurer benchmarks track Medicare, which has cut physician pay for decades based on budgetary guidelines and is not a neutral yardstick.
4. Winning isn’t only on paper. Federal rules require payment within 30 days of an award, yet insurers routinely drag it out for months and don’t pay on roughly 40% of all claims.
His final message: If Congress is going to revisit the NSA, then do it by enforcing prompt payment.
Listen in here:
youtube.com/watch?v=SoeX15xU…
Dan Choi, MD, FAAOS retweeted
My favorite is the “portfolio manager” who makes almost $3MM per year.
Dan Choi, MD, FAAOS retweeted
Make no mistake, the physician, hospital and supporting advocacy community is engaged in a "David v. Goliath" battle to prevent repeal of the #NoSurprisesAct.
The community was one when we defeated the health plans in '18, '19 and early '20 and we will have to come together with one voice again.
One recalls the famous proverb: "It is not the size of the dog in the fight, it's the size of the fight in the dog."
"Health Care Companies Are On Defense. It’s A Windfall For K Street.
POLITICO| Amanda Chu | October 21, 2026 (excerpts below)
Lobbyists and policy analysts said efforts to prepare companies for oversight in a likely Democratic-controlled House, advance proposals in a year-end legislative package, and rethink the No Surprises Act will dominate the agenda for the remainder of the year....
Congress passed the No Surprises Act in 2020 to address out-of-network bills patients received after emergency care, but it has led to outsized claims. The effort to rewrite it has embroiled doctors and insurers. There were approximately 158 lobbying registrations related to the law in the third quarter, up 52% year over year, according to an analysis of public lobbying disclosures by Baron Public Affairs, a government relations consultancy....
“This has become one of the main health care policy arenas, if not the main one,” Riley Kruse, a director at Baron Public Affairs, said of the No Surprises Act....
UnitedHealth, the largest U.S. health insurer, reported $2.1 million in third-quarter lobbying spending, its highest for the period on record. Its peers Centene, Cigna and Humana also reported elevated spending, with Humana recording its highest year-to-date spending for the period.....
"Q3 was my busiest part of the year without question,” said Miranda Franco, senior policy adviser at law and lobbying firm Holland & Knight, the country’s largest health care law practice, which counts hospitals, drugmakers and physician groups as clients.
"It’s the second year of this administration, which means that a lot of the proposals and policy agendas are really taking hold,” said Franco, who is tracking proposed rules spanning the Medicare physician fee schedule and the implementation of the One Big Beautiful Bill Act, President Donald Trump’s domestic policy package that cut nearly $1 trillion in future Medicaid spending....
Lobbyists told POLITICO they expect the scrutiny to continue regardless of the midterm results, which will determine control of Congress. “The pharmaceutical industry is under increasing bipartisan pressure on pricing…The threats are coming at them from all sides,” said a lobbyist for large drugmakers, granted anonymity to speak about their client work....
AHIP, the trade group for insurers, spent $3 million on third quarter lobbying, on par with the prior quarter. Year-to-date spending has surpassed $11.3 million, the group’s second highest for the period behind last year. Chris Bond, a spokesman for AHIP, said it continues to “actively engage with policymakers in support of affordable, high-quality coverage options” and blamed hospitals and drugmakers for high costs.
Spending at the American Hospital Association, meanwhile, is down. The trade group spent $3.8 million on lobbying in the third quarter, its lowest in at least a decade. The association declined POLITICO’s request for comment.
Lobbyists and policy analysts said efforts to prepare companies for oversight in a likely Democratic-controlled House, advance proposals in a year-end legislative package, and rethink the No Surprises Act will dominate the agenda for the remainder of the year.
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Dan Choi, MD, FAAOS retweeted
In 1957, a Russian immigrant published a novel of more than a thousand pages built around one question: what happens if the people who make the world run simply stop?
Its title is Atlas Shrugged. In France it's called La Grève, The Strike. It wasn't even translated into French until 2011. That tells you something.
This morning, I think Elon Musk wrote the sequel.
A. Where the book comes from.
Ayn Rand was born Alisa Rosenbaum in Saint Petersburg in 1905. As a teenager, she watched Bolshevik soldiers walk into her father's pharmacy and seize it in the name of the people. Her family lost everything. Not to a competitor. To a committee.
She fled to America in 1926 and spent the rest of her life writing about one distinction: those who create, and those who seize.
B. The story.
In Atlas Shrugged, America is sliding into decline. Not because of war. Because of rules. Year after year, a growing class of bureaucrats, regulators and planners decides that production must be controlled, shared "fairly," frozen. They never build anything. They issue directives. The worst one freezes every worker in his job and forces every inventor to hand over his patents for the public good.
And one by one, the people who make the country run start disappearing. The best engineers. The industrialists. The inventors. An oil man sets his own wells on fire before vanishing. The whole country keeps repeating a question it doesn't understand: "Who is John Galt?"
John Galt is the man behind the disappearances. He has convinced the creators to go on strike. They withdraw to a hidden valley in the Colorado mountains, where everyone keeps what they make and trades freely. And they let the world find out what it looks like without them.
The lights go out in New York. The grey men are left alone with their directives, and discover that a directive has never produced a single kilowatt.
C. The core idea.
The strike isn't about money. It's about consent.
Rand's insight is that the system that captures the creators runs on their cooperation. It needs them to keep producing so it has something to redistribute. The bureaucrat is a parasite who needs a host. Remove the host, and he's exposed as what he always was: useless.
D. What Musk just did.
This morning, Musk announced that next year he will give one of his own SpaceX shares to every kid in America. "The first of many."
Here's what's fascinating. It's the strike, run in reverse.
Rand's creators withdrew. Musk stays. He keeps building rockets, satellites, AI. But instead of walking away from the system, he walks around it. The value goes straight from the builder to the citizen. No ministry, no agency, no committee in the middle.
Rand had to make the creators disappear to prove the bureaucrats were useless. Musk doesn't need to disappear. He just needs to stop routing value through them. Same result. The grey men are left standing in the middle of a pipe nobody uses anymore.
E. The difference that changes everything.
Rand's strike has a flaw her critics never stopped pointing out: ordinary people are left behind. The creators retreat to their valley. The rest of the country sits in the dark.
Musk's version fixes that. He isn't taking the creators out of the world. He's bringing the world into the valley. Every kid in America becomes a shareholder in the machine. Not a spectator of the strike. A participant.
That's the alliance being formed right now: builders and citizens, directly, with nothing in between. And the only people who lose that deal are the ones who never built anything.
F. Why now, and not in 1957.
In Rand's time, the strike was a fantasy. You couldn't produce at scale without the state's permission, and you couldn't reach every citizen without its pipes.
In 2026, one founder can build rockets, run a global network from orbit, and pledge equity to 73 million children in a single post. AI will soon do in seconds what a ministry does in years. The tools of the strike finally exist. And they don't require anyone to leave.
G. The ending.
For seventy years, "Who is John Galt?" was a shrug. A way of saying nothing can be done.
In the book, the strike ends when the creators decide the road is clear and walk back into the world to rebuild it.
That's the scene we're watching. Not a man leaving. A man coming back, with a gift for every child.
The grey men are about to discover what Rand promised them seventy years ago: a world that no longer needs them.
I don't know if you realize what just happened.
Elon Musk is completely bypassing the State.
For 100 years, we've been told the problem is capital. That it must be captured, taxed, redistributed. With an army of intermediaries standing between those who create wealth and the people: ministries, agencies, commissions, bureaucrats.
Musk is doing the opposite. He's taking his capital and giving it directly to the people. One SpaceX share to every kid in America. Not a handout. Not a subsidy. A piece of the machine that's taking humanity to Mars.
And he says it himself: this is the first of many.
Mises understood this back in 1944: the bureaucrat creates nothing. He administers what others created, following rules that have no connection to the value produced. The day value flows directly from the one who creates it to the one who receives it, the bureaucrat has no function left.
That's what's being born right now. A new liberal world order, where the very concept of the State will make less and less sense.
The world we're entering is a world of abundance. AI, robots, energy, space. And that abundance won't come through the State, for one simple reason: we have a century of proof that it doesn't work.
Redistribution was version 1.0. Direct distribution of capital is 2.0.
While France is still debating how to tax builders even more, America is handing stock to its kids.
Pick your side.
Dan Choi, MD, FAAOS retweeted
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…
Dan Choi, MD, FAAOS retweeted
I find these posts from ‘health system academics’ frustrating and not reflective of the data.
As @pgipe can attest,
Value-based care is not a proven panacea. The term often obscures a broader goal: modifying and consolidating payment systems into vertically integrated silos which are known to add costs.
Payment models encourage consolidation, rely on imperfect or potentially gameable metrics, and impose substantial administrative costs. Even, models that show promise in limited settings often fail to produce consistent savings or better outcomes across the broader health care system.
As in this situation, the strongest advocates are large health-system academics who are often incentivized to promote these models.
Primary care clinicians already have extensive experience with value-based payment systems. They face ever-expanding documentation and reporting requirements, attribution rules, and other administrative burdens and costs that advocates often overlook.
Claims that value-based care is a magical solution are farcical and overstate the evidence.
But let’s keep selling that snake oil
Dan Choi, MD, FAAOS retweeted
I love IDR.
Apparently, an insurance company having to defend what it pays a physician is a national affordability crisis.
Meanwhile, a hospital can buy that physician’s practice and collect more for the same care.
Washington built a financial reward for changing the name on the door.
Start there.
Start with the tax-exempt hospital corporations buying their competitors while taxpayers subsidize the enterprise.
Start with Section 6001, which restricts physician-owned hospital entry and expansion.
Congress actually wrote a law protecting incumbent hospitals from physicians who want to compete with them.
Then everybody sits around wondering why healthcare costs so much.
I build healthcare businesses.
When you subsidize the incumbent, restrict its competition, and pay it more for owning the building, you have engineered an expensive market.
@HHS and @CMSGov: enforce price transparency.
Stop paying a premium for hospital ownership. Congress: repeal Section 6001.
Let physicians build. Let employers buy directly from them.
And keep a process that lets physicians challenge an insurer’s payment without handing the patient a surprise bill.
I’m tired of a healthcare affordability debate that keeps arriving at the independent physician’s paycheck while the subsidized hospital buys another ZIP code.
The No Surprises Act's arbitration system is a disaster. It is distorting negotiations between providers and insurers and is significantly pushing up premiums for American families.
@HammondOnHealth and I explain in the @washingtonpost today.
washingtonpost.com/opinions/… 1/8
Dan Choi, MD, FAAOS retweeted
Health insurance companies should work for patients, not stand in the way of their care. As a physician, I’ve seen how insurance denials can delay treatment and put patients in difficult positions. Our health insurance system needs serious reform that puts patients first and ensures Americans can access the care their doctors recommend.
Dan Choi, MD, FAAOS retweeted
Would add reverse hospital consolidation by removing the moratorium on physician owned hospitals imposed in 2010 by the ACA
4 ways to meaningfully lower health care costs while protecting access:
• Site-neutral Medicare payments
• Limit employer insurance tax breaks for high-income workers
• Rein in Medicare Advantage plan overpayments
• Restrain health care consolidation
healthaffairs.org/content/fo…
Dan Choi, MD, FAAOS retweeted
Policy pundits arguing in favor of cutting doctors pay even more. Look at this graph. Can we agree things cost more now than in 1992? How are doctors supposed to pay their overhead if reimbursement for their services go down year over year? Doctors used to be a respected group. Why don’t people want doctors reimbursement to go up so they can keep their doors open? These policy wonks do understand the most expensive place to receive care is in a large system.
Dan Choi, MD, FAAOS retweeted
An honest primer for physicians on Pallone’s proposed federal payment benchmark(AKA price setting) for out of network physicians and its pitfalls.
The proposal would replace federal surprise-billing arbitration with government-mandated prices.
1. Start with someone else’s 2019 contracts.
Take a plan’s eligible 2019 rates for comparable care in the same specialty and region. Pick the median, or middle price, and adjust it for inflation.
Then impose that payment on physicians who never agreed to those contracts.
2. Use an inflation measure that does not track practice costs.
CPI-U, calculated by the Bureau of Labor Statistics, measures household prices. It includes healthcare spending but does not measure what it costs to run your practice.
Staffing, equipment, and malpractice expenses can rise faster. Adjusting an old price for inflation does not establish that the original payment was adequate.
3. There is still room for ghost-rate abuse.
Ghost rates are contract prices for services a provider does not perform. Low ghost rates can pull the benchmark down.
The bill excludes them but does not expressly require proof that the specific contract price was ever paid. An unused low rate could still qualify if performing the service for another payer satisfies the implementing rules.
4. For qualifying new plans, HHS decides the starting-rate methodology.
For qualifying plans not offered in 2019, the HHS Secretary establishes how the starting benchmark is calculated.
How replacement or substantially redesigned plans qualify remains unclear. As qualifying new plans replace older ones, that authority could affect more payments.
5. The insurer calculates your payment without independent arbitration.
The payer applies the federal formula. Removing arbitration removes a check on inadequate payments and could weaken your negotiating position inside the network too.
6. I don’t trust the enforcement.
The bill requires payment within 30 days. The current IDR system already requires payment within 30 days of a decision, yet physicians still report late and unpaid awards.
I’m not comfortable relying on CMS to enforce payment under another system when physicians are still chasing money owed under the current one.
7. The formula is protected from judicial review.
The bill expressly bars judicial review of the benchmark methodology. That does not necessarily prevent challenges to individual errors or fraud.
I oppose government price setting. Physicians should be able to negotiate their rates without insurers getting the government to impose prices from contracts we never signed.
Dan Choi, MD, FAAOS retweeted
Clutch your pearls: a physician doesn’t want to be a part of your network and believes negotiating a rate.
How inappropriate of them!?
They need to be made examples of…
Insurers and commentators like @LorenAdler and @frankpallone seem to believe independent physicians are second class citizens. Insurers decide whether to include us in network, what they will pay, and then still to control us when we decline to participate.
Physicians should be able to negotiate payment for our work like any other private business. That means having the leverage to reject rates that are too low.
High arbitration awards under the No Surprises Act should give providers leverage to demand higher contract prices.
This looks like TeamHealth beginning to use that leverage in direct deals with employers.
Good reporting from @Marketplace:
marketplace.org/story/2026/1…
Dan Choi, MD, FAAOS retweeted
I love that @JahangirAsgha10 is back and talking about the insane PE law.
I, also, suspect the hospital lobby and large health systems love the proposed corporate practice of medicine ban. It reinforces the regulatory favoritism they already benefit from.
Despite what @DGlaucomflecken implies…
MSOs are used by private equity AND by independent physicians. For independent practices, they allow practices to pool resources, share administrative services and reduce overhead. This is critical for many independent practices in the current environment.
No, the bill doesn’t ban MSOs outright.
But, It does restrict their contracts and management relationships, with no blanket exemption for physician owned MSOs. Requirements for independent advisers and fair market value compensation add compliance obligations.
Meanwhile, hospitals and hospital affiliated clinics are exempt from the core ownership prohibition. Honestly, they are exempt from many of the regulations that apply to physicians.
To be clear, I don’t have an issue with people who object to private equity owning medical practices.
My objection is to leveraging the corporate boogie man to restrict a tool physicians also use to remain independent while preserving the hospital ownership pathway.
The predictable consequence is more legal expense, more compliance risk and greater difficulty operating an independent practice. That gives hospitals another competitive advantage, packaged as protection for physician independence.
Dan Choi, MD, FAAOS retweeted
I, also, suspect the hospital lobby and large health systems love the proposed corporate practice of medicine ban. It reinforces the regulatory favoritism they already benefit from.
Despite what @DGlaucomflecken implies…
MSOs are used by private equity AND by independent physicians. For independent practices, they allow practices to pool resources, share administrative services and reduce overhead. This is critical for many independent practices in the current environment.
No, the bill doesn’t ban MSOs outright.
But, It does restrict their contracts and management relationships, with no blanket exemption for physician owned MSOs. Requirements for independent advisers and fair market value compensation add compliance obligations.
Meanwhile, hospitals and hospital affiliated clinics are exempt from the core ownership prohibition. Honestly, they are exempt from many of the regulations that apply to physicians.
To be clear, I don’t have an issue with people who object to private equity owning medical practices.
My objection is to leveraging the corporate boogie man to restrict a tool physicians also use to remain independent while preserving the hospital ownership pathway.
The predictable consequence is more legal expense, more compliance risk and greater difficulty operating an independent practice. That gives hospitals another competitive advantage, packaged as protection for physician independence.
Dan Choi, MD, FAAOS retweeted
Large hospital systems will charge a 36x markup on an MRI. This is not hyperbole.
Thirty-six times.
Same brain MRI. Same CPT code.
$406 at Henry County Memorial in New Castle, Indiana.
$14,681 at Sky Ridge in Lone Tree, Colorado.
Five years of price transparency. The gap did not shrink. It just got public.
A posted price without a shopper is still a sticker.
Direct care posts the fee before you walk in. The number on the door is the number you pay.
medicalpricecheck.com/resear…
Dan Choi, MD, FAAOS retweeted
Because of the ban on chef-owned restaurants, the chef described below can only open a food truck.
Congress then mandates that the restaurant he left gets paid 5x for the exact same hamburger. In fact, if the restaurant opens a food truck right next to our chef, it's still considered part of the restaurant and gets paid 5x for the same food.
Prices are obscured from the customers, of course.
Oh, and congress also mandates that the restaurant gets a 50% discount on ingredients.
Now our chef is wondering why the restaurant always seems flush with cash and his food truck is barely scraping by.
That's how site specific payments & 340B work to suppress independent physician practices.
Imagine a chef employed at a restaurant that charges $100 for a hamburger.
One day he gets sick of his institution ripping off customers, so he goes across the street and opens a shop with $5 hamburgers.
Now the hamburger loving people are better off. Competition drives down prices and increases quality.
The original restaurant, angry over the lost business, gets a law passed that bans chefs from owning restaurants.
Everyone would recognize this as a corrupt, protectionist law.
And yet, in healthcare, with skyrocketing costs, we still outlaw physician owned hospitals.
Dan Choi, MD, FAAOS retweeted
Doctors: "Hey, electronic health records, I've spent a substantial portion of my life performing data entry for you. Thousands of billing codes, diagnosis codes, orders, notes, etc. Can I access any of that data?"
EHR: "lol no"
Doctors: "Ok, how about just a list of my own patients and their diseases?"
EHR: "lol no"
Doctors: "What about my billing metrics? A list of my procedures? My own clinic patients? CPT codes?"
EHR: "lol no"
Doctors: "What can you provide?"
EHR: "how do you like this cartoon cow splash page I made?"
Dan Choi, MD, FAAOS retweeted
An economist just told a room of doctors that American health insurance isn't insurance.
"In the United States, we don't have health insurance.
What we have is a system where I don't pay for my health care — I pay for yours.
You don't pay for your health care — you pay for mine.
This isn't insurance. It's a social policy."