Nearly 15% of in-network hospital admissions included at least one out-of-network professional claim, according to a new Health Care Cost Institute report.
HCCI discovered that the percentage of out-of-network claims varied by state. Florida had the highest level at 26.3%. California, Kansas and New Jersey all had more than 20% of admissions. That's compared to just 1.7% of in-network hospital admissions that resulted in out-of-network charges in Minnesota.
Anesthesiologists (16%) were the medical professionals with the highest percentage of out-of-network professional claims in an in-network hospitalization. The next highest were for primary care (13%) and emergency care (12%). On the other end, hematology/oncology specialists were the lowest percentage of admissions that resulted in a surprise bill (1%). Also, independent labs were considered out-of-network 22% of the time.
Surprise medical bills can lead to hefty out-of-pocket costs and federal and state policymakers are working on the problem. CMS recently said it will require ACA plans to report denial reasons, including out-of-network, referral or prior authorization needed and services not covered. That requirement will allow researchers to get a better handle on why payers deny claims.
One proposal introduced on Capitol Hill last year is a bipartisan effort called the Protecting Patients from Surprise Medical Bills Act. The legislation would cap out-of-network charges to 125% of the average amount payers pay in the surrounding geographic area.
Hospitals largely oppose that idea. Hospital groups sent a letter to congressional leaders in February protesting using a "fixed payment amount or reimbursement methodology for out-of-network services."
HCCI reviewed 620,000 in-network inpatient admissions for people under 65 with employer-sponsored health insurance. The percentage of out-of-network claims connected to emergency care could be even higher if all ER visits are analyzed. HCCI only focused on admissions, so the report doesn't take into account all the patients who aren't admitted to the hospital after an emergency visit.
A recent analysis by USC-Brookings Schaeffer Initiative for Health Policy showed that about 20% of ER visits involved an out-of-network provider that can lead to a surprise bill.
Surprise billing isn't just an issue for people with employer-sponsored health plans. A recent Kaiser Family Foundation report estimated that 19% of claims submitted for in-network service for Affordable Care Act marketplace plans in 2017 were denied. Another KFF report found that about 40% of Americans acknowledged they had received a surprise medical bill.
A few attempts at curbing the practice have come forward. Sen. Maggie Hassan, D-N.H., proposed another bill that would use binding arbitration to determine the allowable charges. The bill would limit patient cost-sharing responsibility to the cost of the service in-network.
Meanwhile, Rep. Lloyd Doggett, D-Texas, filed a bill that would require hospitals to notify patients if a provider treating them may be considered out of network. The bill would also forbid them to charge same-day ER services at beyond in-network prices.
Surprise billing laws on the state level are lacking. The Commonwealth Fund said that most states don't have comprehensive laws in place to directly protect consumers from surprise bills.