Changes Needed to Address Out-of-Network Billing at Hospitals

Requiring hospitals to sell a package of facility and physician services would protect patients from out-of-network bills at in-network hospitals, according to a report published online Dec. 16 in Health Affairs.

Zack Cooper, Ph.D., from Yale University in New Haven, Connecticut, and colleagues used data for 2015 from a large commercial insurer to assess out-of-network billing for care delivered at in-network hospitals.

The researchers found that at in-network hospitals, 11.8 percent of anesthesiology care, 12.3 percent of care involving a pathologist, 5.6 percent of claims for radiologists, and 11.3 percent of cases involving an assistant surgeon were billed out of network. At hospitals in concentrated hospital and insurance markets and at for-profit hospitals, out-of-network billing is more prevalent. If these specialists were not able to bill out of network, it would lower physician payments for privately insured patients by 13.4 percent and reduce health care spending for people with employer-sponsored insurance by 3.4 percent (approximately $40 billion annually).

“When physicians whom patients cannot avoid can work out of network from in-network hospitals, it exposes patients to significant financial risk and raises physicians’ in-network payments,” the authors write.

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