Ed Gaines

As a subtle reminder: my tweets are my own; my employer or trade organizations where I am board member or speaker have nothing to with my tweets or the thoughts expressed therein. #healthlawyertweets

Welcome to the ‘26 fall in NC—70-75 degrees and gorgeous—the fall colors have been as bright as I’ve ever seen but maybe too that’s ‘cause I’m a new Grandpa!

I was going to go w/ “G-Daddy” until someone said that there is someone by that name—so going for now with “G-Pop—then when she’s older, I am full on “G-Daddy”!

The incoming chair of @EDPMA and managing partner of Wake Emergency Physicians PA (WEPPA), in central and eastern NC, one of the largest independent ED groups in the Southeast, Dr. Jenn Raley, explains how the lack of enforcement of the #NoSurprisesAct (NSA) IDR awards has caused major negative impacts on their practice.

Jenn was recently highlighted in the @NYT article regarding the health plans’ systemic refusal to pay IDR awards and rampant non-compliance w/ federal law. nytimes.com/2026/11/03/us/…

WEPPA was in network w/ all of the BUCA payors, most for over a decade, until the NSA was passed and the health plans attempted to foist ~30-40% cuts for their in network rates. The group could not financially accept those cuts and went out of network.

She calls on Congress during the Lame Duck session beginning on 11/9/26 to pass H.R. 4710, The No Surprises Act Enforcement Act, that would increase penalties for non-compliance with payment of awards and provide additional enforcement authority to CMS.

Dr. Raley goes beyond the headlines, explaining how insurers' failure to negotiate in good faith hurts independent physician practices. acep.org/news/acep-news…

1/ Classic move by health plans to get out of the public forum of the courts and force parties into arbitration which can be private and confidential. But here it failed.

Physicians and hospitals should be careful to check if their health plan agreements demand arbitration; while not legal advice, for certain issues arbitration is ok but others it is not.

Judge denies Aetna’s bid to force Jefferson into arbitration over Medicare Advantage reimbursement policy beckerspayer.com/legal/judge-de…

With the additional health plans reporting after my Oct. 31st post on their YTD net profits, @CIGNA @CVSHealth @Humana have now reported their Q3 '26 earnings.

For the 7 for profit health plans, net profits for Q1-Q3 '26 are ~$38,000,000,000, w/ Q4 yet to be reported.

So when the plans talk about how affordability is being negatively impacted by physicians, hospitals, the #NoSurprisesAct and other "dog ate my term paper" type excuses, let's not believe them for a second.

I'll keep saying it--there's plenty of money in healthcare, but we have a distribution problem with the health plans siphoning off profits while decrying everyone else's roles in affordability.

CVS to split into 2 companies & reports Q3 '26 net profits. beckerspayer.com/financial/cvs-…