Most spine and orthopedic practices treat network participation as a prerequisite for building volume, staying busy and keeping the lights on. But Anthony Maioriello, MD, challenged that assumption at Becker’s Spine, Orthopedic and Pain Management-Driven ASC + The Future of Spine Conference in Chicago from June 11-13
“What is your motivation to sign a contract that gives you Medicare, or in Dallas, less than Medicare?” Dr. Maioriello. “Why would you do that?”
Dr. Maioriello is the founder and owner of Comprehensive Level One Staffing, based in Dallas, which specializes in surgical staffing and hospital service line development. He also runs Level One Revenue Recovery, which helps physicians and facilities arbitrate underpaid out-of-network claims through the No Surprises Act‘s independent dispute resolution process.In 2015, after years of chasing commercial payers who wouldn’t pay, he walked away from $4.5 million in accounts receivable.
“Nobody would pay us,” he said. “That was before the No Surprises Act.”
The law, passed in 2020 and implemented in 2022, was designed to protect patients from surprise bills. But embedded in it was a federal arbitration process that lets out-of-network providers dispute what insurers paid them. The arbitrator looks at two numbers — what the insurer offered and what the provider billed — and picks one.
“They have to decide, is zero reasonable for a lumbar fusion or is $200,000 reasonable for a lumbar fusion?” Dr. Maioriello said. “One would argue both are unreasonable, but this one’s more unreasonable, therefore, you win.”
The awards, he said, typically run eight to 12 times the original payment. The process applies only to commercial insurance — not Medicare, Medicaid, Tricare or Medicare Advantage — and only to out-of-network providers at in-network facilities. Some states have their own surprise billing laws that run parallel to the federal process; in the remaining states, all qualifying claims go through the federal IDR process.
Awareness of this process lags, Dr. Maioriello said, noting that he encounters the same patterns regarding the No Surprises Act across his network of colleagues.
“A lot of it is either no one’s heard about it, or there’s a misunderstanding about it,” he said. “Or, now, there’s negative press about it because the insurance companies, instead of paying the bill, they’re just putting out negative press.”
The “negative press,” he argues, provides clear insight into the dynamic. He said insurers often publicize large awards without disclosing what they originally offered. The framing obscures the dynamic, making it appear that payers are losing at arbitration because their initial payments are so low that almost any award looks outsized by comparison.
“Until they start offering more than $1,000 for a case or $2,000 for a case, we’re going to have these really large awards,” he said.
The deeper argument Dr. Maioriello makes is about what network participation actually costs a practice — not in contract terms, but in operational overhead. Getting busy enough to justify the discounted rates requires more staff, more administrative infrastructure, more people fighting denials. The math, he says, rarely works out the way practices assume it will.
“Is it better to do 40 cases a month and make X or 10 cases a month and make X?” he said. “It’s better to do 10 cases a month and make X because you don’t have to have as much staff, you don’t have to have as big of a machine to keep that funnel coming in.”
He underscores that a practice should not drop every contract, and the calculus depends on market, specialty and payer mix. The more practical entry point, he said, is selective. A practice can stay in network with its dominant payer and go out of network for everything else — arbitrating emergencies and call cases against payers that consistently underpay. The No Surprises Act’s inadvertent provider designation, which covers physicians patients don’t choose in advance — anesthesiologists, radiologists, assistants — creates additional arbitration opportunities for groups that structure their employed providers correctly.
“That concept of not killing yourself to make more money — how do I just be smarter about what I’m doing?” he said. “I think we all have to do that, especially when we’re all struggling to get paid.”
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.
