The People v. The White-Coat Cartel

The doctor’s lobby makes hundreds of millions controlling the language of your medical bills. A new lawsuit is threatening to burn down the business model.

Friday afternoon, an email landed in my inbox with the kind of subject line that makes me pause: “PRA Sues AMA to Make Medical Billing Codes Freely Available to the Public.” It was from Cynthia Fisher.

You guys. This is a good one.

For those of you who don’t know Cynthia - you should. A business owner and entrepreneur, she has spent her money and her winsome stubbornness on something almost nobody with her resume bothers to fight for: making American health care prices public. She founded PatientRightsAdvocate.org (PRA) in 2017 and has been the single most relentless force behind hospital and health plan price transparency rules ever since.

She’s functionally the reason any of us can look up what a hospital actually charges for anything.

The price transparency files, that Cynthia and I fought so hard to require be posted, really can be hard to access, read and interpret. That’s exactly the problem that PRA tries to solve - they post every file as an excel spreadsheet, for free, on their website. So they need to be able to publish the CPT codes and the short description associated with each code on their website in order to fulfill their mission. They also grade every hospital twice a year on its compliance with the reporting requirement. In other words, PRA is a national treasure.

So, if Cynthia is suing you, you’re bad. You’re on the wrong side of history. You’re corrupt. You’re fleecing patients and employers and everyone else who pays for sick care.

If you haven’t done much investigation into the dealings of the American Medical Association, you might be surprised to see them listed as the opposition. Aren’t they supposed to be the good guys?

Most doctors don’t even think so.

In the 1950s, the AMA represented 75 percent of American doctors. Today it’s closer to 15 percent, and even that number is generous, because the AMA’s own membership totals fold in medical students and residents who aren’t even billing anybody yet.

That kind of collapse would kill most trade associations. It didn’t kill this one, because the AMA stopped depending on its members a long time ago. Instead they’ve transformed their business model into the shenanigans outlined quite nicely in Cynthia’s lawsuit.

Cliff’s Notes on the Suit

Ok, the Cliff’s Notes version (do non-GenXers even know what that means?): every time doctors bill for anything - a checkup, a stitch, an MRI - they use a five-digit code from something called Current Procedural Terminology, or CPT. It’s not optional. Medicare requires it. Medicaid requires it. Every HIPAA-covered transaction requires it. Forty-five-plus states require it too. Skip it, get it wrong, or try to work around it, and you can eat a civil penalty of up to $50,000 per violation.

So CPT is, functionally, the law.

It’s baked into federal regulation so completely that you can’t legally bill for most health care without it, period. Which is why your ACA or employer-sponsored plan also requires it in order to pay their share of your medical bills.

Nice health care system you got there. Be a shame if anything happened to it.

And the people who wrote the first draft own the copyright. The AMA claims to own CPT outright and charges you for the privilege of looking at it - $137.89 for a physical copy of the codebook. $82.50 up front plus $18.50 per user per year if your practice, hospital system, insurer, or vendor wants electronic access, and every biller and coder in your building needs a seat. Multiply that across every hospital, insurer, and vendor in the country and you can see how the business model generates sweet, sweet cash: $296.4 million in “books and digital content” revenue for the AMA in 2025, netting $267.5 million in profit. CPT royalties alone reportedly clear $300 million a year off a coding system nobody in America is legally permitted to avoid using.

With that kind of annual cash, at least the AMA is successfully lobbying for doctors to get better pay and working conditions every year. Oh wait.

The $137.89 sticker price on a codebook is bad enough. But the scandal doesn’t stop there. Even more insidious is what AMA’s control over CPT codes does to the entire, multi-trillion dollar market that’s a fifth of the U.S. GDP. They are controlling the codes that every plan uses to pay… THEM. And you can bet your butt that they are distorting those codes in their own interest and not “solely in the interest of plan beneficiaries” - to quote the legal standard that every plan fiduciary has to follow when paying service providers with a health plan’s assets. And to be clear, when I say “their own interest,” I mean the AMA’s institutional and financial interest - not the interests of most doctors.

Hospitals and insurers have spent years slow-walking every price transparency rule anyone’s tried to force on them, and now here’s the AMA fighting in court anyone who tries to make the item descriptions on that menu public too. Hiding what something costs, apparently, wasn’t sufficient. They went after your ability to even know what the thing was called.

“No One Can Own the Law.” The AMA Apparently Missed That Memo.

On August 13th, PatientRightsAdvocate.org filed suit against the AMA in federal court in the Northern District of Illinois, and their legal theory is refreshingly blunt: you can’t copyright the law, and CPT is the law in every way that matters.

PRA leans on a doctrine the Supreme Court reaffirmed just a few years ago in Georgia v. Public.Resource.Org - when a standard gets incorporated by reference into a government regulation, the private party that wrote it doesn’t get to keep charging for it. The complaint argues CPT clears that bar in three ways: the AMA exercises what amounts to delegated lawmaking authority in maintaining it, it’s incorporated wholesale into federal regulations, and the government itself co-authored parts of it.

Beyond that, PRA argues plain old fair use - nonprofit, noncommercial re-publication of a standard incorporated into law is about as clean a fair use case as exists in copyright doctrine.

PRA also argues my personal favorite, copyright misuse, as the Ninth Circuit called it in its 1997 ruling in Practice Management Info. Corp. v. AMA. The court recognized that the AMA had misused its CPT copyright over a backroom deal it cut with the government: the AMA let the government use CPT for Medicare billing, and in exchange, the government agreed never to adopt a competing coding system. The AMA was using the government’s own regulatory muscle to guarantee itself a permanent, captive customer with zero competition, forever, at a price it alone got to set.

As a feign to that ruling, the AMA supposedly “renounced” the exclusivity clause to satisfy the court order, but by that time, the rot was so entrenched in every health care transaction in the country, that the exclusivity was already baked into everything, with or without AMA’s insistence.

The cartel takes any threats to its racket seriously.

I’ve had my own run-ins with the organized medical mafia. Years ago, working for a U.S. Senator, I recommended he co-sponsor a bill letting Certified Registered Nurse Anesthetists (CRNAs) practice at the top of their license and bill independently for standard surgical anesthesiology services they were already performing, unsupervised, every day. Here’s the arrangement the bill would have chipped away at: one anesthesiologist MD sits in a back office, doesn’t touch a single patient, and collects the professional fee for six CRNAs actually doing the work in the operating room, while those CRNAs get paid a fraction of what their labor generates.

The state anesthesiologist cartel didn’t respond with a strongly worded letter or a polite meeting request. Its leader walked up to me in a hallway, put his literal finger in my chest, and informed me that his group had a very close relationship with the Senator, had invested heavily in his career, and expected him to deliver accordingly. Just one of the many House of Cards moments in my government career.

The state’s university system, not wanting the anesthesiologists to have all the fun, later went after my job over the same bill - because I’d used what their hospital‘s CRNAs had told me about how the 6:1 nurse/MD ratio worked, to help make the public case for the legislation. Nobody disputed that the exploitation was real. What got their whining lobbyists on the phone was a Senator daring to say it out loud, with the nurses’ own quotes attached.

This is why I reach for the words I reach for when I write about them: “cartel,” “gangsters,” “mafia,” a “white-coat-religious cult” that treats its own rank-and-file as revenue units whenever that’s convenient, and treats anyone who threatens the revenue model - patients, nurses, employers, legislative staffers, competitors, entire nonprofits founded by biotech executives - as an enemy combatant to be intimidated, litigated, or fired into silence.

Same playbook, hospital edition.

If the CPT fight sounds familiar, it should. PRA is currently defending itself against a completely separate lawsuit the American Hospital Association (AHA) filed back in December, in the very same Illinois courthouse, over PRA’s plan to publish the UB-04 manual - the hospital-billing equivalent of CPT. In this case, PRA provoked the lawsuit by notifying the AHA of their intention to transparently post the information in the manual. The AHA sued first, seeking a permanent injunction and statutory damages. UB-04 licenses aren’t cheap either - the 2026 edition runs from $182 for one user up to $4,523 for 33 to 50 users, scaled like a bad SaaS pricing model for a product you’re legally required to buy.

And this isn’t the AHA’s first rodeo, losing when they try to hide prices, either. Go back to the first Trump administration’s hospital price transparency rule, which forced hospitals to post negotiated rates (you’re welcome, America). The AHA sued to block it, arguing patients didn’t have a right to know prices in advance. They got laughed out of federal district court, appealed to the D.C. Circuit, and got laughed out of there too, unanimously. Two-for-two, total defeat, and they’re still out here today running the identical playbook - sue first, delay, threaten, hope the other side runs out of money - against anyone who tries to make their billing paperwork legible to the people paying for it.

It doesn’t have to work this way

CPT isn’t the only mandatory coding system in American medicine. When your plan is billed, the bill includes the CPT code showing what service was rendered, but also why it was rendered, i.e. the diagnosis code. These diagnostic codes, known as the ICD-10-CM, are maintained by the CDC, federally mandated and baked into every claim just like CPT.

Also, completely free.

You can download the entire current-year file from a government website right now, no license, no per-seat fee, no $50,000 penalty, because the agency that maintains it treats a mandatory code as infrastructure, the same way it treats highway signage or a zip code. Weird, right?

CPT is the odd one out. It alone got claimed by a private trade group early enough, and lobbied hard enough for long enough, that it’s still treated as somebody’s intellectual property fifty-plus years later, generating $300 million a year for an organization pretending to represent doctors.

One Final Argument

When the federal government finally forced hospitals and health plans to post their prices - the hospital price transparency rule from the first Trump administration, and the Transparency in Coverage rule for insurers that came later in the first term - it didn’t ask for a vague range of potential prices. The rules required every hospital and health plan in the country to post actual negotiated rates, service by service, alongside cash price and sticker price, in free, public, machine-readable files that anyone can download right now, no account and no dime required. If you add the government’s own published Medicare fee schedules on top of that, also free and public, then every category of rate in American health care is sitting out in the open.

And virtually every line of every one of those files is identified by a CPT code, because that’s the coin of the realm.

So yeah, the government already requires every hospital and health plan in America to publish, for free, an enormous dataset entirely organized around CPT codes - including their supposedly proprietary short description of what each code stands for - codes the AMA insists that nobody like PRA may reproduce or give away without paying first.

Remember, you pay for those codes every day, even if you don’t buy access from AMA. You pay for them in the taxes that fuel almost half of all spending on health care in this country - the half that is paid for by government. The feds mandated the exact activity the AMA claims to own the exclusive right to license. Every one of those files complies with federal law by doing a version of exactly what PRA is asking a judge’s permission to do: attaching public information to a CPT code and putting it online for free.

At least these gangsters work for us.

Practically speaking, the government has already normalized the exact outcome the AMA calls catastrophic: CPT-tied information, at massive scale, free to the public, happening every day, because of these transparency rules. The AMA’s business model depends on Americans believing that free access to CPT is dangerous, even though the government’s own rules already prove otherwise, at a scale dwarfing anything PRA is proposing.

PRA and Cynthia aren’t the only ones to notice this corrupt model.

CMS’ proposed rule on 2027 physician payments, published in July, specifically asked for public comment on the “harms or challenges associated with AMA’s monopoly over CPT-4 licenses.”

Senator Bill Cassidy, chairman of the Senate committee overseeing HHS (and always eager to remind everyone, as the first sentence of every tweet or speech, that he’s a physician himself), has publicly accused the organization of abusing a “government-backed monopoly” and charging “exorbitant fees.”

In other words, litigation, congressional scrutiny, and active rulemaking are all converging on the same target at once.

Why This Costs You

You can’t audit a bill written in a language you’re not fully allowed to read, share, or build tools around, and you can’t negotiate a fair price for a medical service when the code that defines it is licensed and priced by the trade group lobbying to keep the system opaque.

Every price transparency win I’ve celebrated in this space - the machine-readable files, the posted rates, the progress toward patients and employers actually being able to make decisions based on price - depends on the vocabulary of billing being genuinely usable by the public, not just technically postable in a format nobody can parse. Right now that vocabulary is rented, from a guild that’s spent decades making sure the dictionary stays just illegible enough to protect the racket.

If you’re an employer or benefits leader, you already know the practical version of this, even if you’ve never thought about the CPT copyright. As a plan fiduciary, you have a legal duty to spend your people’s health care dollars prudently, and every vendor you hire to audit claims, every reference-based pricing plan, every TPA trying to build you a smarter network, is working with a vocabulary kept deliberately hard to use at scale.

I don’t know exactly how the lawsuit shakes out (though it seems slam-dunk to me). Courts move slowly, and both the AMA and the AHA in these legal fights with PRA have already vowed to “vigorously defend” their “intellectual property” (LOL).

You don’t hate these two groups enough.

Go read the complaint. Then go pull up your last Explanation of Benefits and get mad about it all over again, because it’s the same racket, hiding behind the white coats you trust, and - for now, anyway - the same hidden dictionary standing between you and understanding your own medical bill.

If a hospital or a physician group has ever played games with you, your practice, your legislation, or your paycheck, you already know why this lawsuit matters. Plenty of people have grumbled about this for decades. Nobody with Cynthia’s money and guileless stubbornness has ever so completely threatened the AMA’s empire. If PRA wins - and I believe they will - it’s the death knell for half a century of billing-code extortion masquerading as intellectual property. It can’t happen fast enough.