> standard of American healthcare in price-gouging patients

They were charging MediCare, not patients, and they were charging MediCare according to the price schedule dictated by MediCare, which was significantly less than insurance companies paid. The problem was there were poorly worded rules for adjusting prices when one doctor was simultaneously treating multiple patients, particularly around how multiple discount factors should compound.

I don't remember the exact details from 30 years ago, but IIRC, it was something like under one interpretation of the rules, if a doctor were treating 2 private insurance patients and 1 MediCare patient simultaneously, then the MediCare discount factor was reasonable. However, if a doctor were treating 3 MediCare patients simultaneously, under one interpretation the discount factors compounded additively such that the doctor's fees went negative and the doctor was best off doing the 3rd case pro-bono. The real trouble came when a doctor was treating 1 patient with private insurance and 2 under MediCare, where the incorrect reading resulted in discount factors unreasonable compounding, but not to such a degree that it was so clearly an incorrect interpretation.

When MediCare didn't respond to their request for clarification, my dad's company went with the interpretation that gave sane results for 3 MediCare patients, and applied that same interpretation to the 2 MadiCare patient case. It would have been immoral and illegal for them to refuse to treat the patients, so they went forward in good faith with the most sensible interpretation. This despite (as discovery showed) MediCare officials acting in bad faith by intentionally not responding to their inquiry and privately joking about it. They presumably realized the correct interpretation resulted in higher fees, but avoided responding in hopes the lower fees would be charged.

Whichever bureaucrats had written the original billing rules were clearly aware that some doctors simultaneously treated multiple patients, but had clearly hadn't sat down and tried calculating a bill for one hypothetical situation for each of the possible corner cases.

The rules were later amended to be unambiguous. The lawsuit was filed a few years after the rules amendments, and all of the allegations of wrongdoing were for billing prior to the rules amendments. Everything they did was always clearly correct under the later rules. The only question was if the earlier and later rules were equivalent. My dad's company's assertion was that the earlier ambiguous rules should be interpreted as being equivalent to the later rules. The opposition's assertion was that the rules change wasn't in fact a clarification, but instead a meaningful change that allowed doctors to bill more.

The billing rules were so complex that in the late 1970s, my dad's company of 15-ish doctors hired some developers to spend months sitting down with the doctors coding up the billing rules. Even the mid 2000's they were making more on licensing the anesthesia billing software than they were on providing anesthesia services.

Don't go into medicine unless you really like helping people.

My dad studied hard enough to get very high MCAT scores and went to med school after 3 years of undergrad, so he never got an undergrad degree. (Med school was less competitive in the 1970s, and he didn't go to a top-tier med school, though he did well enough that he did his residency at the Mayo Clinic.) I'm pretty sure there were plenty of other things my dad could have done that would have been roughly as lucrative, but lower stress and left him with more time with family. I think part of it was that he felt a duty to carry on his father's career that was cut so short.

I saw my dad's paycheck one month in the mid 1980s. He made 10k/month, which was good money for the 80s (about 300k/yr in 2021 dollars), but he also had to pay malpractice insurance and med school loans out of that (Grandpa drowned when dad was 9 years old and Grandma had to go back to being a school teacher). He and many of his colleagues had stress-related acid reflux. Hospitals need anesthesia 24/7, so he was on a rolling shift work schedule. Sometimes I wouldn't see him for a week because he'd either have the evening shift and be out before I got home from school, or he'd be working the graveyard shift and wouldn't wake up until after my bedtime. Anesthesiologists have pretty high rates of suicide and drug abuse. You occasionally pull some genuine miracles out of your hat and save a doomed person, but you also carry with you forever the names of those you couldn't save.