The problem with the second one is that it was very vague. What’s “usual and customary?” For 25 years, we had used a percentage of charges through Ingenix, which was put together and supported by United Healthcare, which was a charge database owned by the insurance industry. Well, that fell apart when the state of New York sued them for fraudulent behavior and there was a $300 million settlement that paid for a new type of database called FAIR Health that was transparent and independent, etc. However, Ingenix was clearly flawed, and it was also fraudulent.

The question was, What does “usual and customary” mean? We had people go to the Hill and meet with CCIIO multiple times. Then they suddenly released the final rule after all this work, and it came out with “usual and customary” amounts. In effect, the insurance companies could pay us whatever they wanted because that is a black box for us. For the first time ever, and the only specialty society to do so, we sued CMS.

The judge agreed with us that CCIIO had not been forthcoming on why they’d made this decision. They did not follow the rules of the registry, and the judge directed the agency to discuss specifically what “usual and customary” means.

With our legislative and relationship ducks in a row, we expect the judge to say, “CMS, you have to correct this, you have to look at this, you have to explain yourself.”

Out-of-network has been more of a focus than I anticipated—we were able to build that consensus through the AMA to prepare us for solutions coming up into the next state legislative cycle, and to be able to get a partial favorable decision on our CCIIO lawsuit tops it off. That became all-encompassing, and it was a surprise to me that it would move this quickly, but I’m hopeful that we’ll finish it up soon.

KK: Can you speak about your successes with diversity and inclusion? Why is this important to the membership?

RP: The topic came up when I was running for President. I spoke from the position of a woman emergency physician when I talked about diversity and inclusion. I saw this as an opportunity in terms of leadership development within the organization.