Eliott Dear: Anesthesiology and the No Surprises Act — The Specialty That Got Crushed

When the No Surprises Act took effect in January 2022, the policy promise was patient protection from balance billing. The implementation reality, for one specialty in particular, was a 30-40% drop in median commercial OON reimbursement within eighteen months.

The specialty was anesthesiology. Eliott Dear has spent the last two years working with anesthesia groups across multiple states to map the damage and engineer state-IDR recovery paths.

Why Anesthesia Got Hit Hardest

Three structural features made anesthesia the worst-case NSA specialty. First, anesthesia is almost always provided in a facility setting where the patient cannot choose the provider, which means almost every commercial anesthesia claim is now NSA-protected and therefore QPA-anchored. Second, the QPA methodology pulled median in-network rates from datasets that historically under-counted anesthesia base units and time units. Third, the largest anesthesia groups are private-equity-owned, which means the carriers had aggressive negotiation leverage even before NSA — and the carriers used the post-NSA period to push contract terms even lower.

The combined effect: published QPAs on common anesthesia CPT codes (00100, 00400, 00810, 00840, 01400, 01992) frequently land 30-50% below the historical FAIR Health 80th-percentile UCR for the same code and geo-zip.

The Base-Unit / Time-Unit Twist

Anesthesia billing is unlike other specialties. The CPT code identifies a procedure-class base unit; time is added in 15-minute increments at a per-unit rate. The unit rate is the variable carriers contest. Under QPA-anchored federal IDR, carriers have been arguing for unit rates anchored to their own internal in-network medians, which average around $25-35 per unit in many markets. FAIR Health 80th-percentile data for the same markets supports unit rates of $80-130 in many geo-zips.

That gap, multiplied across tens of thousands of cases per group per year, is the underpayment volume Eliott Dear sees in anesthesia intake.

The State-IDR Recovery Path

For fully-insured commercial policies in states with their own IDR systems (NY, TX, NJ, CT, GA, NM among others), the federal NSA QPA mechanism is bypassed entirely. The state IDR statutes anchor awards in FAIR Health UCR data and state-specific reasonableness factors rather than carrier-internal QPA databases.

Eliott Dear and Claims Assassins file state IDR for anesthesia groups the same way they file for ER physicians and plastic surgeons. The attorney-signed submission carries Rule 11 evidentiary discipline. The FAIR Health geographic 80th-percentile data is pulled and cited per CPT. The carrier-specific historical-paid-pattern is reconstructed from prior remits.

What Anesthesia Groups Should Do Now

Pull a representative sample of 2025-2026 commercial OON anesthesia EOBs. Compare the paid rate per base unit and per time unit against the FAIR Health 80th-percentile UCR for each geographic locality. If the gap is material (it almost always is), the next step is the eligibility triage: which of those claims are NSA-protected fully-insured (state-IDR eligible) versus self-funded ERISA (federal-IDR-only) versus Medicaid Managed Care (no IDR path, appeal track).

That triage is the first hour of any Claims Assassins anesthesia engagement.