Out-of-Network Bills Common for Some Pathologists, Other Specialists

Out-of-network billing occurs infrequently for most specialty providers, but a select few always or nearly always bill out of network for inpatient and outpatient services, according to a new report from the Health Care Cost Institute (HCCI).

Analyzing claims data on 13.8 million visits in 2017, HCCI researchers found that 36 percent of pathologists billing out of network for inpatient visits and 20 percent of pathologists billing out of network for outpatient visits did so more than 90 percent of the time.

In contrast, almost no cardiologists billed out of network that often. In fact, most providers who billed out of network did so less than ten percent of the time, researchers reported.

Among the six medical specialties studied, the share of providers billing out of network more than 90 percent of the time was also similar, ranging between five and eight percent for inpatient visits and 10 to 16 percent for outpatient visits. The specialties included pathology, emergency medicine, radiology, anesthesiology, behavioral health, and cardiovascular services.

Pathologists were the worst offenders for out-of-network billing, the report showed.

About 44 percent of pathologists had at least one out-of-network claim associated with an in-network inpatient stay, and 33 percent of pathologists had at least one out-of-network claim associated with an in-network outpatient visit.

Out-of-network billing occurred almost as often among emergency medicine specialists, with 44 percent submitting an out-of-network claim for an in-network inpatient stay and 49 percent with out-of-network claims for an in-network outpatient visit.

However, only five percent of emergency medicine providers always or nearly always had an out-of-network claim for an in-network inpatient stay. Frequent out-of-network billing was more common among outpatient emergency medicine visits (16 percent), but not nearly as the share of pathologists.

Overall, less than half of specialists studied billed out of network, researchers stated.

The share of providers in the six medical specialties studied who had at least one out-of-network claim associated with an in-network inpatient stay ranged from 18 percent for cardiology to 44 percent for emergency medicine. The share of providers with at least one out-of-network claim associated with an in-network outpatient visit ranged from 15 percent for behavioral health to 49 percent for emergency medicine.

“Consistent with previous work, these findings show that out-of-network billing practices are not common across providers,” researchers wrote in the report. “However, as the flurry of media reports of the last year indicate, those who do receive a surprise bill are often subject to tens of thousands of dollars of unexpected costs.”

Understanding the variation in out-of-network billing across specialties will be key to creating targeted policy solutions, researchers added.

“This is important to ensure that people are not unfairly saddled with medical bills for unknowingly receiving services from an out-of-network provider,” they wrote.

These surprise medical bills were at the center of health policy discussions last year, with several proposals from lawmakers seeking to prohibit the practice. However, efforts to protect patients from excessive, unexpected medical bills stalled at the close of last year as hospitals and payers lobbied for different solutions.

Generally speaking, hospitals and provider groups advocated for proposals that would implement an arbitration process for resolving surprise medical bills. Meanwhile, the groups lobbied against a solution largely backed by payers – benchmark payment rates for out-of-network care.

But surprise medical bills are coming back into the spotlight as the number of individuals losing employer-sponsored coverage spikes in light of the coronavirus outbreak and its toll on the economy. Hospitals receiving grants through the coronavirus stimulus packages had to agree to stop balance billing COVID-19 patients. The Trump Administration has also indicated a new push to end surprise medical bills, possibly as part of the next coronavirus rescue package, Politico recently reported.