I think maybe I did a bad job of explaining. Of course providers have teams to deal with getting approvals from, submitting to, and disputing with, all the vari

I think maybe I did a bad job of explaining. Of course providers have teams to deal with getting approvals from, submitting to, and disputing with, all the various Payers. At this level, we can consider all the Payers roughly equivalent. But for Medicare/caid, there's an ADDITIONAL layer of work that CMS requires Providers to perform. The Providers need to ensure they're compliant with all kinds of standards, and jump through hoops to document and prove to CMS that they're compliant. These standards aren't limited to the specific care - procedures, meds, etc. - being expended on a particular patient. They encompass the entirety of the Provider's operations. For example CMS makes Providers provide documentation about their average pay rates, stuff that's not related to the care of any given patient. The existence of that additional layer of reporting and compliance is the work that they're offloading onto the Providers, and thus increasing costs of providing care without it being legible if you were to audit CMS's own expenses.