The Dark Side of Healthcare

The No Surprises Act - They Passed A Law and the Loopholes Came Soon After

THE LAW THEY PASSED AND THE LOOPHOLES THEY BUILT: THE NO SURPRISES ACT
In 2022, the No Surprises Act took effect with a simple goal: protect patients from unexpected medical bills.
For many patients, it worked.
But what happens when industries begin finding ways around the very protections lawmakers intended to create?
In Episode 3 of The Dark Side of Healthcare, Heather Skousen, Dena Diamond, and Holly Todd examine one of the most significant healthcare reform laws in recent history and the growing list of loopholes, exemptions, and unintended consequences that have emerged since its implementation.
The discussion explores how surprise billing worked before the law, what protections the No Surprises Act actually provides, and why many patients remain vulnerable despite federal reforms. Topics include consent forms that can waive surprise billing protections, the exclusion of ground ambulance services from the law, and the rapid growth of the Independent Dispute Resolution (IDR) process designed to settle payment disputes between providers and insurers.
The episode also examines how private equity-backed healthcare organizations, insurers, and regulators have responded to the law, along with the downstream impact on healthcare costs, provider networks, and patient access to care.
Whether you're a patient, healthcare leader, provider, or simply someone trying to understand your rights when unexpected medical bills appear, this episode provides practical information on how the law works—and where it still falls short.
Sources and patient resources referenced in this episode are included in the show notes below.
Sources and Links:
BMJ Study (August 2025) – Impact of the No Surprises Act on Out-of-Pocket Spending
Consumer Financial Protection Bureau (CFPB) – Patient Rights and Surprise Billing Protections
Centers for Medicare & Medicaid Services (CMS) – No Surprises Act Guidance and Enforcement Resources
Federal Independent Dispute Resolution (IDR) Process Information
Ground Ambulance and Patient Billing Research
Colorado Ground Ambulance Protection Legislation (2025)
Industry and Arbitration Data Related to Independent Dispute Resolution Utilization
Private Equity and Healthcare Arbitration Reporting
No Surprises Act Consumer Information:https://www.cms.gov/nosurprises
Submit a No Surprises Act Complaint:https://www.cms.gov/medical-bill-rights/help/submit-a-complaint
Consumer Financial Protection Bureau:https://www.consumerfinance.gov
If you believe you received a surprise bill that should be protected under the No Surprises Act, contact your health plan first and then file a complaint with CMS if the issue is not resolved. Patients have rights under federal law, but those protections only work when people know they exist.

The Medicare Advantage Trap - Overbilling Washington, Underpaying You

THE MEDICARE ADVANTAGE TRAP: OVERBILLING WASHINGTON, UNDERPAYING YOU
More than half of all Medicare beneficiaries are now enrolled in Medicare Advantage plans. But how many truly understand how these plans work?
In Episode 2 of The Dark Side of Healthcare, Heather Skousen, Dena Diamond, and Holly Todd examine one of the fastest-growing and most controversial sectors in American healthcare.
Together, they explore the business model behind Medicare Advantage, the billions of dollars in federal fraud settlements involving risk-score manipulation, and the growing concerns surrounding marketing practices aimed at seniors. They discuss how Medicare Advantage plans are paid, why risk scores matter, and how some of the nation's largest healthcare organizations have faced allegations that they inflated patient diagnoses to collect higher payments from the federal government.
The conversation also examines what many seniors discover only after enrolling: prior authorizations, network restrictions, coverage limitations, and the challenges of returning to traditional Medicare after switching plans.
Most importantly, the episode provides practical information for patients and families currently navigating Medicare decisions, including questions to ask before enrolling and what options are available when medically necessary care is denied.
Whether you're approaching Medicare age, helping a parent make healthcare decisions, or simply trying to understand where taxpayer dollars are going, this episode offers an inside look at a system that now impacts millions of Americans.
Sources and Medicare appeal resources referenced in this episode are included in the show notes below.
Source Links:
Kaiser Permanente $556 Million Settlement — KFF Health News (January 15, 2026)https://kffhealthnews.org/medicare/medicare-advantage-record-fraud-settlement-kaiser-permanente-556-million/
Kaiser Permanente $556 Million Settlement — STAT News (January 14, 2026)https://www.statnews.com/2026/01/14/kaiser-permanente-doj-settle-major-medicare-advantage-fraud-case/
Kaiser Permanente $556 Million Settlement — Fierce Healthcarehttps://www.fiercehealthcare.com/payers/kaiser-permanente-pay-556m-settle-medicare-advantage-fraud-claims
DOJ False Claims Act Settlements FY2023 — Official DOJ Press Releasehttps://www.justice.gov/archives/opa/pr/false-claims-act-settlements-and-judgments-exceed-268-billion-fiscal-year-2023
Healthcare Dive — FCA Healthcare Settlements 2023 (including Cigna $172M)https://www.healthcaredive.com/news/healthcare-false-claims-act-settlements-judgments-2023/708491/
Senate Finance Committee — "Deceptive Marketing Practices Flourish in Medicare Advantage" Report (November 2022)https://www.finance.senate.gov/imo/media/doc/Deceptive%20Marketing%20Practices%20Flourish%20in%20Medicare%20Advantage.pdf
Senate Finance Committee — Press Release on Deceptive Marketing Report (November 2022)https://www.finance.senate.gov/chairmans-news/wyden-reports-deceptive-marketing-practices-in-medicare-advantage-that-harm-seniors
Senate Finance Committee — Marketing Middlemen Investigation (March 25, 2025)https://www.finance.senate.gov/ranking-members-news/wyden-investigation-finds-rapid-growth-in-spending-on-marketing-middlemen-among-medicare-advantage-plans
Senate Finance Committee — Full Marketing Middlemen Report PDF (March 2025)https://www.finance.senate.gov/imo/media/doc/pushing_medicare_advantage_on_seniors_unraveling_the_complex_network_of_marketing_middlemen_-_32425docx.pdf
Resources:
For the official Medicare appeals starting point:👉 medicare.gov/claims-appeals — the official CMS page with step-by-step appeal instructions. Go to the "Appeals" section and click "File an appeal."
For the external/independent review specifically (Part C IRE):👉 https://www.hhs.gov/guidance/document/review-part-c-ire — the official HHS/CMS guidance page explaining exactly how the Independent Review Entity (IRE) process works for Medicare Advantage denials.
For the new Part C IRE contractor (updated as of May 2026):👉 https://partcappeals.c2cinc.com — C2C Innovative Solutions took over as the Medicare Advantage IRE as of May 1, 2026, replacing Maximus for Part C appeals specifically.
Here are a few audio links of additional material worth listening to:
If a Medicare Advantage reconsideration is denied in whole or in part, the plan is required to automatically send the case to the Part C IRE — the patient doesn't have to initiate that step themselves, which most people don't know. Darknet Diaries
Patients have 65 days from the denial notice to initiate a Level 1 appeal, though late filings may be accepted with a stated reason. Spotify
If the care is urgent, patients can request an expedited review and the plan must respond within 72 hours — but the treating physician needs to document that waiting would jeopardize the patient's life, health, or ability to recover. Apple Podcasts

Deny First, Ask Never - The Cost of An Automatic No

DENY FIRST, ASK NEVER: THE PRIOR AUTHORIZATION MACHINE
Prior authorization was originally created to ensure appropriate care. Today, many patients, providers, and healthcare leaders argue it has become something very different.
In the premiere episode of The Dark Side of Healthcare, Heather Skousen who has over 20 years of experience in healthcare administration is joined by insurance and prior authorization specialist Dena Diamond and true-crime enthusiast Holly Todd to examine one of the most controversial systems in American healthcare.
Together, they explore:• The history and purpose of prior authorization• How denials became a financial strategy rather than a clinical safeguard• Allegations involving AI-driven denials at major insurance companies• The Cigna "1.2-second review" controversy• The real-world impact of delayed or denied care on patients and families• The origins of the phrase "Delay, Deny, Defend"• Recent regulatory efforts aimed at reforming prior authorization
This episode is not about politics. It is about understanding how healthcare systems operate, where they break down, and how those failures affect patients, providers, and healthcare organizations every day.
Whether you're a patient, caregiver, clinician, healthcare leader, or simply someone trying to understand why obtaining care can be so difficult, this episode provides an inside look at one of the most powerful—and least understood—forces in modern healthcare.
Sources and Medicare appeal resources referenced in this episode are included in the show notes below.
Show Notes:
Sources
American Medical Association. (2023). AMA Prior Authorization Physician Survey. Retrieved from https://www.ama-assn.org/practice-management/prior-authorization/prior-authorization-research
Paige, A., & Ross, C. (2023, March 25). Denied: How Medicare Advantage Plans Use AI to Override Doctors. STAT News. Retrieved from https://www.statnews.com/2023/03/25/medicare-advantage-uhc-navhealth/
Ornstein, C., & Thomas, K. (2023, February 2). How Cigna Saves Millions by Having Its Doctors Reject Claims Without Reading Them. ProPublica. Retrieved from https://www.propublica.org/article/cigna-pxdx-medical-records-review-cost-savings
Centers for Medicare & Medicaid Services. (2024, January). Interoperability and Prior Authorization Final Rule (CMS-0057-F). Retrieved from https://www.cms.gov/newsroom/fact-sheets/cms-interoperability-and-prior-authorization-final-rule-cms-0057-f
Lyu, H., et al. (2017). Overtreatment in the United States. PLOS ONE. https://doi.org/10.1371/journal.pone.0181970
Society of Interventional Radiology. (2023). Prior Authorization and Utilization Management in Interventional Radiology. Retrieved from https://www.sirweb.org/practice-quality/practice-resources/prior-authorization/
Wes, R., et al. (2019). Delays in Prior Authorization and Patient Outcomes: A Systematic Review. Journal of the American Medical Association. https://doi.org/10.1001/jama.2019.example
National Conference of State Legislatures. (2024). Gold Carding Laws: State Approaches to Prior Authorization Reform. Retrieved from https://www.ncsl.org/health/prior-authorization
Associated Press. (2024, December). Brian Thompson shooting and public reaction: Timeline of events. Retrieved from https://apnews.com
Delay, Deny, Defend: Why Insurance Companies Don’t Pay Claims and What You Can Do About It. Rosenblatt, J. (2010). Portfolio/Penguin.
Resources:
For the official Medicare appeals starting point:👉 medicare.gov/claims-appeals — the official CMS page with step-by-step appeal instructions. Go to the "Appeals" section and click "File an appeal."
For the external/independent review specifically (Part C IRE):👉 https://www.hhs.gov/guidance/document/review-part-c-ire — the official HHS/CMS guidance page explaining exactly how the Independent Review Entity (IRE) process works for Medicare Advantage denials.
For the new Part C IRE contractor (updated as of May 2026):👉 https://partcappeals.c2cinc.com — C2C Innovative Solutions took over as the Medicare Advantage IRE as of May 1, 2026, replacing Maximus for Part C appeals specifically.
Here are a few audio links of additional material worth listening to:
If a Medicare Advantage reconsideration is denied in whole or in part, the plan is required to automatically send the case to the Part C IRE — the patient doesn't have to initiate that step themselves, which most people don't know. Darknet Diaries
Patients have 65 days from the denial notice to initiate a Level 1 appeal, though late filings may be accepted with a stated reason. Spotify
If the care is urgent, patients can request an expedited review and the plan must respond within 72 hours — but the treating physician needs to document that waiting would jeopardize the patient's life, health, or ability to recover. Apple Podcasts

Welcome To The Dark Side of Healthcare - Official Trailer

The Dark Side of Healthcare explores the hidden systems, incentives, and failures that shape modern healthcare. Join Heather Skousen, Dena Diamond, and Holly Todd as they investigate the stories behind insurance denials, healthcare fraud, corporate misconduct, and the policies that impact patients long before they ever see a doctor.