- If specialties notorious for surprise billing were not allowed to bill out of network, physician payments for privately insured patients would drop 13.4% and total healthcare spending for people with employer-sponsored insurance would fall by 3.4%, or about $40 billion annually, according to research published Monday in Health Affairs.
- The study, which used 2015 claims data from an unnamed large commercial insurer that covers tens of millions of lives throughout all 50 states, found that claims involving pathologists were most likely to involve and out-of-network bill (12.3%), followed by anesthesiology (11.8%), assistant surgeons (11.3%) and radiologists (5.6%).
- The research also found that out-of-network billing was most common at for-profit hospitals and in areas with highly concentrated provider and payer markets. The practice was found most often in Alabama, Idaho, Mississippi and Montana.
The study is one of many in recent months to show the scourge of surprise billing, which catches patients off guard and stuck with an exorbitant cost from an out-of-network provider, often despite treatment occurring at an in-network facility.
Negotiations over a federal ban on surprise billing have waxed and waned throughout the year, but got a shot in the arm last week when a bipartisan group of key committee leaders from both chambers announced a compromise plan.
Provider and payer lobbies, which have fought with deep pockets to push the version of a ban they prefer, did not seem appeased by last week's agreement. That opposition, as this session's clock runs out and lawmakers also face a government funding deadline, leaves the chances for a bill making its way to the White House this year extremely slim.
On Monday, Senate health committee Chairman Lamar Alexander, R-Tenn., punted the issue to next year. "I will continue to do everything I can to keep surprise medical bills at the top of the congressional priority list until it's done," he said in a statement.
Other research has shown that services most frequently cited in surprise bills had substantially increasing markups in recent years far exceeding inflation, as many as one in five ER visits involve an out-of-network provider and 16% of anesthesiology claims were from an out-of-network provider treating a patient at an in-network facility.
The Health Affairs study authors, students and faculty from Yale University, noted that while surprise billing is a major problem, out-of-network billing creates additional issues. "When physicians whom patients do not choose and cannot avoid can bill out of network while working within hospitals that are in network with their patients' insurers, it strengthens physicians' outside options in negotiations with insurers and raises in network payment rates," they wrote. "These higher in-network payments get passed along to all consumers in the form of higher insurance premiums."
The researchers suggested requiring hospitals to sell a bundled package of services that included fees for specialty physicians who are often out of network. Hospitals have previously said they staunchly oppose bundling services.