- Most providers rarely issue out-of-network bills, but a small number that bill out of network do so almost every time, according to a new report from the Health Care Cost Institute.
- Pathologists were the most frequent offenders, with more than a third who billed for inpatient visits doing so on an out-of-network basis more than 90% of the time. Roughly one-fifth of pathologists billing for outpatient visits issued out-of-network bills more than 90% of the time.
- The analysis of almost 14 million claims across six specialties from 2017 comes as the White House is reportedly renewing its efforts to issue a surprise billing fix in the next round of coronavirus aid.
Surprise billing was at the epicenter of the health policy discussion at the close of last year, though a fix failed to make it into year-end spending legislation despite the bipartisan push. Lawmakers stalled amid fierce industry lobbying between two vehicles for setting disputes between providers and health insurers: third-party arbitration, which providers support, or a set rate for out-of-network services, which payers support.
But the issue is growing in importance as the coronavirus sparks an unprecedented economic downturn, causing millions to lose their jobs and their employer-sponsored insurance, experts say. Though hospitals that receive a portion of the $175 billion in congressional funding are banned from surprise billing COVID-19 patients for testing and treatment, there are many reports of patients receiving out-of-network bills for those services, including one man in Denver shocked by an almost $140,000 medical bill for COVID-19 treatment.
The new HCCI study is consistent with past research showing the majority of providers don't issue surprise bills in suggesting a small but productive group of specialists account for a disproportionately large slice of the out-of-network billing. HCCI is funded in part by health insurers which also provide claims data to help power HCCI's analysis of industry trends.
Less than half of specialists bill out-of-network, HCCI researchers found. The proportion of providers with at least one out-of-network claim for inpatient visits ran the gamut from 18% for cardiology to 44% for emergency medicine. For outpatient visits, the share of providers with at least one out-of-network claim ranged from 15% for behavioral health to 49% for emergency medicine.
Most providers billing out-of-network do so only 10% of the time, though there were specialties like pathologists billing out-of-network always or almost always.
By comparison, the share of providers that billed out-of-network more than 90% of the time was significantly lower, ranging from 5-8% for inpatient visits and 10-16% for outpatient visits, HCCI found.