Dr. Norman Rowe, a plastic surgeon with offices in New York and Florida, advertises on his website that breast reduction surgery usually costs between $15,000 and $25,000.
But these days, his practice sometimes earns $440,000 for the procedure.
Dr. Rowe has taken full advantage of a new arbitration system, part of a major consumer protection law Congress passed in 2020 with bipartisan majorities. The No Surprises Act was designed to eliminate surprise medical bills, for patients who showed up in the emergency room and were treated by a doctor who didn’t take their insurance.
It bars those out-of-network doctors from billing patients directly. Instead, they can plead their case to a government-approved arbitrator. If they win, the patient’s insurer has to pay their desired amount.
By all accounts, the law is successfully protecting patients against bills from doctors they never chose. But it has also generated an expensive unanticipated consequence: Doctors have flooded the arbitration system with millions of claims. Most are winning, often collecting fees hundreds of times higher than what they could negotiate with insurers directly or what they could have earned from patients before the law passed.
“I’m still glad we passed the bill, because we got consumers out of it, but we need to rein in this arbitration process,” said Representative Frank Pallone Jr., Democrat of New Jersey, who helped negotiate the law.
Some health plans said they have increased premiums this year to cover the extra costs. The United Service Workers health plan, which covers 20,000 trades workers in the New York area, said it boosted premiums by an extra 1.75 percentage points to offset arbitration awards and fees. The system has also enriched a new class of specialized businesses, which assist doctors in navigating the bureaucratic process.
“This is a recipe for driving up health care costs,” said Karen Ignagni, the chief executive of EmblemHealth, which sued Dr. Rowe in March, arguing his use of arbitration amounted to fraud. “There are no checks. There are no balances. There’s no oversight.”
When the law passed, government officials estimated that about 17,000 cases would go to arbitration a year. Instead, doctors brought 1.2 million such cases in the first half of last year, and won around 88 percent of them.
The arbitrators are doing well too. The fees they earn for deciding cases, which range from $425 to $1,150 per case, have added up. They earned $885 million from 2022 to 2024.
In arbitration, doctors and insurers each propose a price for the care, along with arguments for why it is appropriate. An arbitrator must pick one of the two numbers, and there is no opportunity to appeal the decision.
Arbitrators have repeatedly approved doctors’ submissions of extremely high prices for common medical procedures, according to court filings and a New York Times analysis of a large public data set with basic information on each dispute.
A neurosurgery practice outside of Philadelphia went to arbitration after the health plan Highmark offered its standard payment of $2,660 for a diagnostic procedure to measure blood flow to the brain. An arbitrator awarded it $333,000 instead. A New Jersey anesthesiologist was awarded $14,560 in 2025 for an X-ray-guided steroid injection.
Many claims that shouldn’t be eligible for arbitration, such as those for patients covered through the government programs Medicare and Medicaid, move through the system anyway. The claim from the New Jersey anesthesiologist involved a patient on a UnitedHealthcare Medicare Advantage plan, according to a lawsuit that UnitedHealth has filed protesting the arbitration decision.
The doctor’s billing company recognized the submission was a mistake, and tried to withdraw it before the decision. But his lawyer, Eric Katz, said that the arbitrator clearly thought the award was appropriate.
“No one put a gun to anyone’s head,” he said. “If the plans have issues with the way this is being handled, take it up with Congress.”
Medical specialties like spinal and plastic surgery, for which surprise bills were rare before the law, now frequently have cases in arbitration, according to the public data. Some practices are using the law to obtain high payments for routine medical care, including gynecologists who have won fees 600 times higher than usual rates for placing intrauterine contraceptive devices, or I.U.D.s.
The money does not always end up with the doctors but instead can go to the owners of their practices. The Times interviewed two physicians who show up repeatedly in public data files. Both said they were salaried workers and uninvolved in the claims filed under their names.
The government has hired 15 firms, some boutique vendors and others large contractors, to arbitrate billing disputes. Doctors and insurers can select a firm if they agree, or be randomly assigned one if they do not.
Health policy experts have been surprised to see such lopsided results that favor doctors. Some argue that because the arbitrators are paid per case, they may have an incentive to render decisions that keep doctors coming back.
Arbitrators may also, like the broader public, prefer doctors to insurers, said Matthew Fiedler, a senior fellow at the Brookings Institution who has studied the law. “Arbitrators are people, and the typical person likes physicians.”
David Farber, a lawyer for the newly formed Coalition of Independent Dispute Resolution Entities, a trade group representing some of the arbitration firms, disputed the notion that arbitrators acted improperly.
“We’re getting the job done,” he said. “And the job is getting done consistent with how Congress set the process up to work.”
Doctors contend that they only pursue arbitration when insurers offer unreasonably low payments.
“We have very strong preference to be in network at sustainable rates,” said Dr. Richard Heller, a senior vice president at Radiology Partners, which employs over 4,000 radiologists. The company now has 150 staff members working to bring arbitration claims.
‘Eyebrow-raisingly high’
Dr. Rowe has practiced for decades on New York City’s Park Avenue and in New Jersey. Last winter, he opened an office in Palm Beach, a few miles from President Trump’s Mar-a-Lago resort. Just before the inauguration, he told The New York Post the office had been overrun with clients who wanted to look good when they “have face time with the leader of the free world.”
Dr. Rowe did not respond to multiple requests for comment from The Times.
On social media, he flaunts a lavish lifestyle. An Instagram post in February detailing his 60th birthday party featured a performance from the rapper 50 Cent and a custom-cake recreation of his 1950s vintage Porsche.
Health insurers do not cover many of the elective procedures that Dr. Rowe provides, such as penis enlargement. That service became a big enough part of his practice that he has trademarked the nicknames “Dr. Penis” and “Doctor Penis.”
Breast reductions, however, are different. They are often treated as medically necessary because they can reduce back and neck pain.
Before the No Surprises Act, Dr. Rowe’s practice was out of network with EmblemHealth, but he accepted fees $30,000 or lower for hundreds of breast reduction surgeries, the lawsuit claims.
In 2024, the lawsuit says, he started routinely performing surgeries on EmblemHealth patients in hospitals that accepted the insurer’s in-network payments, though he still did not.
Under the No Surprises Act, doctors in such situations can provide patients with a waiver that warns of additional costs. If patients sign that form, the doctor has permission to bill them directly.
Dr. Rowe does not hand out that waiver. That allows him to take his payment disputes to arbitration.
He and his practice have filed more than 6,000 arbitration claims, according to an analysis of public filings from the Georgetown University Center on Health Insurance Reforms. He has won more than 85 percent of his cases.
The lawsuit offers details about five of those cases, all for elective breast reduction surgeries.
In the first case, in November 2024, Dr. Rowe won a payment of $112,500 that covered his work and the work of an assistant surgeon. In the fifth one, in late December 2025, his practice brought and won separate claims for each surgeon, totaling $440,000. Altogether, the practice won more than $1.4 million from those five surgeries alone.
EmblemHealth’s strategy also changed over time. According to the suit, the company started with a low counteroffer, around $6,000. Over time, it tried offering fees as high as $124,000, but continued to lose. The plan’s lawyers also started including language in their briefs stating that Dr. Rowe “has a pattern of exploiting” the process.
Dr. Rowe’s briefs to the arbitrator are not public, so it is unclear exactly what arguments he made to justify the much higher rates he was claiming in arbitration. The law directs arbitrators to consider several factors, including the usual price insurers pay, the doctor’s experience and the patient’s complexity.
Elevance Health, another insurer, said that breast reduction surgeries are now its most expensive category of arbitration claims. Ariel Bayewitz, the company’s vice president of health economics, said one Connecticut plastic surgery practice has escalated its earnings from the procedure, beginning at $70,000 in 2024 and hitting $440,000 late last year.
Michael Gottlieb, the lawyer who handles Dr. Rowe’s arbitration filings, declined to speak about continuing litigation but did broadly defend his clients’ seeking much higher amounts than insurers typically pay. He described the arbitrators as having “reverse sticker shock” at how low the health plan payments were.
“When they got wind of three-digit payments for massive, complex surgeries and they know they pay their plumber more to fix a toilet, they just gravitate toward the providers’ offers even if they do seem eyebrow-raisingly high,” he said.
Arbitration decisions are supposed to be binding, but Mr. Gottlieb said that health plans often refuse to send payment. He has sued multiple insurers over the issue.
In March, one doctor he represents received a letter from the Motion Picture Industry Health Plan, which provides coverage to many film workers. The letter, which The Times reviewed, stated that the plan would not pay the amount an arbitrator selected because it “does not constitute appropriate use of plan assets.”
Silence in Congress
For years before the No Surprises Act passed, surprise billing was an urgent topic in Congress. Lawmakers from both parties denounced the high bills that ambushed patients.
But these days in Washington, the law’s unexpected results are rarely discussed. Instead, many legislators who worked on the law emphasize the success of consumer protections.
“My focus is on ensuring everyone can get the care they need without worrying about the cost,” said Patty Murray, Democrat of Washington, who helped craft the bill.
Senator Bill Cassidy, Republican of Louisiana and a physician, who helped write the law, said the large awards were a sign that insurers were not making reasonable offers.
”If they’re winning, it’s because the insurance companies are not coming back with a reasonable thing,” he said.
In late 2023, the Biden administration proposed changes to the arbitration system, including more scrutiny of ineligible claims. The Trump administration has not yet put into place those reforms.
Only one bill has been introduced in Congress to change arbitration, and it would increase penalties on insurers that fail to pay doctors quickly after cases are concluded.
Seeing little movement in Washington, health plans have turned to the courts. They have filed at least 20 lawsuits against doctors and the companies they use to submit claims.
But this month judges in California and Florida dismissed two such cases, finding that Congress did not intend for judges to review the arbitration awards.
If an insurer believes doctors are acting improperly, the Florida judge wrote, it should “raise the issue” in arbitration.
Catie Edmondson contributed reporting.
Sarah Kliff is an investigative health care reporter for The Times.
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