August 12, 2019
Eric C. Sun, MD, PhD1,2; Michelle M. Mello, JD, PhD2,3; Jasmin Moshfegh, MA, MSc2; et alLaurence C. Baker, PhD2
Author
Affiliations Article
Information
JAMA Intern Med. Published online August
12, 2019. doi:10.1001/jamainternmed.2019.3451
Key
Points
Question What
are the incidence and financial consequences of out-of-network billing for
inpatient admissions and emergency department visits?
Findings In
this analysis of 5 457 981 inpatient admissions and 13 579 006 emergency
department admissions between 2010 and 2016 in a large national sample of
privately insured patients, the incidence of out-of-network billing increased
from 32.3% to 42.8% of emergency department visits, and the mean potential
liability to patients increased from $220 to $628. For inpatient admissions,
the incidence of out-of-network billing increased from 26.3% to 42.0%, and the
mean potential liability to patients increased from $804 to $2040.
Meaning It
appears that out-of-network billing is becoming more common and potentially
more costly in both the emergency department and inpatient settings.
Abstract
Importance Although
surprise medical bills are receiving considerable attention from lawmakers and
the news media, to date there has been little systematic study of the incidence
and financial consequences of out-of-network billing.
Objective To
examine out-of-network billing among privately insured patients with an inpatient
admission or emergency department (ED) visit at in-network hospitals.
Design,
Setting, and Participants A retrospective analysis using
data from the Clinformatics Data Mart database (Optum), which includes health
insurance claims for individuals from all 50 US states receiving private health
insurance from a large commercial insurer was conducted of all inpatient
admissions (n = 5 457 981) and ED visits (n = 13 579 006) at in-network
hospitals between January 1, 2010, and December 31, 2016. Data were collected
and analyzed in March 2019.
Exposures Receipt
of a bill for care from at least 1 out-of-network physician or medical
transport service associated with patient admission or ED visit.
Main
Outcomes and Measures The incidence of out-of-network billing and the
potential amount of patients' financial liability associated with
out-of-network bills from the admission or visit.
Results Of
5 457 981 inpatient admissions and 13 579 006 ED admissions between 2010 and
2016, the percentage of ED visits with an out-of-network bill increased from
32.3% to 42.8% (P < .001) during the study period, and the mean (SD)
potential financial responsibility for these bills increased from $220 ($420)
to $628 ($865) (P < .001; all dollar values in 2018 US$). Similarly,
the percentage of inpatient admissions with an out-of-network bill increased
from 26.3% to 42.0% (P < .001), and the mean (SD) potential financial
responsibility increased from $804 ($2456) to $2040 ($4967) (P < .001).
Conclusions
and Relevance Out-of-network billing appears to have become common
for privately insured patients even when they seek treatment at in-network
hospitals. The mean amounts billed appear to be sufficiently large that they
may create financial strain for a substantial proportion of patients.
Introduction
In the
United States, physicians who are part of an insurer’s network typically agree
to accept a set amount from the insurer as payment in full for their services.
However, out-of-network physicians can seek additional payment from the
patient, a practice known as out-of-network or balance billing. Many clinicians
have a standard charge for their services that is larger than the rate paid by
the insurer. Under out-of-network billing, physicians may bill the patient for
the difference between the 2 amounts. This amount increases the patient’s
financial responsibility beyond any coinsurance or copayments under the terms
of the patient’s insurance plan. Although federal legislation bans balance
billing for Medicare beneficiaries,1 no
federal protections against out-of-network billing for privately insured
patients exist. In particular, while the Affordable Care Act prevents insurers
from levying additional copayments for out-of-network emergency department
care, these protections do not prevent out-of-network billing by physicians.2 As
of June 2019, 25 states had enacted legislation providing patients some
protection against out-of-network billing, ranging from dispute resolution
processes to provisions holding the insurer responsible for the balance-billed
amount; these protections, however, are rarely comprehensive.3,4 In
other states and the Congress, pending legislation would limit the scope and
effects of out-of-network billing.3,5,6
In
theory, out-of-network billing could benefit patients by providing flexibility
for them to see out-of-network physicians. Such flexibility would require the
patient to be aware in advance that the physician is out-of-network and may
send a balance bill. More commonly, however, the patient is unaware of these
possibilities. For example, at many hospitals, some physicians (eg,
anesthesiologists) are not hospital employees and make decisions separate from
the hospitals about participating in insurance. Thus, even if the hospital and
the admitting physician are in-network, the patient could still be cared for by
out-of-network physicians and be sent balance bills.
Although
out-of-network billing has received news media attention,7-10 to
date there has been little systematic study of its incidence and financial
consequences. Studies have examined the incidence of out-of-network billing by
emergency department (ED) physicians,11-13 but
to our knowledge billing by other physicians and ambulance transport services
has not been fully explored. One report analyzed out-of-network billing for air
ambulances,14 and
studies have examined the incidence but not the financial liabilities of
out-of-network billing for inpatient admissions.15,16
Using a
national data set of people with private health insurance, we characterized the
incidence and potential financial consequences of out-of-network billing among
patients undergoing an ED visit or inpatient admission at in-network hospitals
between 2010 and 2016.
Methods
We
obtained data from the Clinformatics Data Mart database (Optum), which includes
health insurance claims for individuals from all 50 US states receiving private
health insurance from a large commercial insurer,17-19 with
approximately 13 million covered lives annually.20,21 The
individuals in the database represent about 19% of those with commercial health
insurance,15 and
their geographic distribution broadly matches the geographic distribution of
the US population.22 We
used claims submitted between January 1, 2010, and December 31, 2016. Data were
collected and analyzed in March 2019. For each claim, the database reports
information such as service dates (ie, physician specialty or medical transport
service) and whether the claim was paid as in-network or out-of-network. In
addition, each claim reports financial variables including the amount charged
by the clinician and a standardized cost, which broadly represents the national
mean amount insurance companies would pay an in-network clinician or medical
transport service (ie, ambulance) for the service. The database has been used
in a variety of health services and health policy studies.17,23,24 As
the study used deidentified data, the Stanford University Institutional Review
Board (IRB) determined it did not meet the definition of human subjects
research and therefore required no further review from the IRB or written and
informed patient consent.
The
initial sample consisted of all inpatient admissions (n = 6 454 236) and ED
visits (n = 17 073 129) to in-network hospitals between January 1, 2010, and
December 31, 2016. We confined the analysis to care received at in-network
hospitals because unexpected out-of-network billing from physicians would be
more likely in this setting. Inpatient admissions were directly identified in
the data by a unique coded identifier which is assigned to all claims (ie,
hospital claims, claims for services performed by physicians) associated with a
given inpatient admission. In constructing the sample of inpatient admissions,
we included admissions from the emergency department as well as admissions from
other sources (ie, elective admissions), and excluded admissions to observation
status. We identified ED visits by searching for claims with a procedure code
consistent with an evaluation and management visit in the ED setting (Current
Procedural Terminology codes 99281-99285). Any claims submitted on the
same day as a claim with the relevant ED codes (ie, claims submitted for
consults from other specialties) were considered to be associated with that ED
visit.
After
construction of the initial sample, we excluded visits and admissions with claims
for charges that were either $0 or negative (n = 92 901 ED visits; 76 688
inpatient admissions) and those for which the network status of the clinician
or medical transport service was unknown or missing (n = 3 264 060 ED visits;
864 435 inpatient admissions). Last, visits with charges in the top 1% of all
visits and admissions (n = 137 162 ED visits; 55 132 inpatient admissions) were
removed to avoid the inclusion of outliers, resulting in a final sample of
13 579 006 ED visits and 5 457 981 inpatient admissions. A flow diagram
outlining sample construction is available in the eFigure in the Supplement.
We
analyzed 2 primary outcomes. The first outcome was whether the patient received
any out-of-network bill during the inpatient admission or ED visit, which was
directly reported on the claim. In measuring this outcome, we restricted the
analysis to claims submitted by physicians (of any specialty) or medical
transport services. The latter was included because patients typically have
little choice about their transport and thus may be more likely to be subject
to unexpected out-of-network billing.14
The
second outcome was the amount of money the patient could potentially be liable
for as a result of having received care from the out-of-network clinician or
medical transport service. Consistent with previous work,11,25 this
amount was defined as the difference between the amount charged by the
out-of-network physician or transport service, which is directly reported, and
the amount the insurer would pay in-network for the same service. For the
in-network payments, we used the standardized costs included in the database.
Although the actual amount the insurer may have paid an in-network clinician or
transport service for a specific claim may be higher or lower, this approach
can provide reliable estimates for national-level analyses, and has been used
in previous studies.25 All
dollar values are reported in 2018 US$.
For
1 080 616 ED visits (20.4%) and 547 467 inpatient admissions (27.1%), the
patient’s estimated potential financial responsibility was negative (ie, the
amount charged by out-of-network physicians and/or medical transport services
was less than the standardized mean cost). For these visits and admissions, we
set the patient’s potential additional financial liability to $0, and also
performed sensitivity analyses, as described below. We adjusted all dollar
amounts to 2018 dollars with the Consumer Price Index.26
Statistical
Analysis
We
calculated the incidence of out-of-network billing (defined as ED visits or
inpatient admissions with at least 1 out-of-network physician or medical
transport service) and the patient’s potential financial liability on an annual
basis. We calculated the incidence of out-of-network billing by physician
specialty and medical transport service for the entire sample period. We
characterized the distribution of out-of-network billing across hospitals by
calculating the percentage of ED visits and inpatient admissions to a given
hospital that resulted in at least 1 out-of-network bill. In calculating these
hospital-level measures of the incidence of balance billing, hospitals with
fewer than 100 inpatient admissions (n = 5771 of 9067 hospitals) or 100 ED
visits (n = 5151 of 9179 hospitals) during the sample period were excluded.
We
assessed the statistical significance of differences across groups with a t test
for continuous variables and a χ2 test for discrete variables,
using Stata, version 14.0 (StataCorp Inc). All tests were 2-sided with P < .05
indicating statistical significance.
Sensitivity
Analyses and Subgroup Analyses
With a
subgroup analysis, we examined the incidence and magnitude of out-of-network
billing for medical and surgical inpatient admissions separately. Surgical
admissions were defined as admissions in which the patient received care (ie,
≥1 claim submitted) by a physician from a surgical specialty, such as general
surgery, orthopedics, and obstetrics and gynecology (eTable 1 in the Supplement).
The
main analysis assigned a potential financial responsibility of $0 to the
patient in situations where the out-of-network physician or medical transport
service charged less than the insurer’s in-network payment. With 2 sensitivity
analyses, we explored the consequences of this decision. The first reanalyzed
the data after excluding these cases, and the second included them and assigned
them the mean potential financial responsibility for that year.
In
another sensitivity analysis, we included the 13.3% of inpatient admissions and
19.1% of emergency department visits excluded from the main analysis because
the network status of at least 1 involved physician (or the medical transport
service) was unknown. This analysis conservatively treated any physician or
medical transport service whose network status was unknown as in-network.
Although
patients generally would have little choice of physician or medical transport
service for ED visits and emergency inpatient admissions, they could have more
choice for elective inpatient admissions (ie, choosing an out-of-network
surgeon to perform an elective surgery), so out-of-network billing, if it
occurred, would not necessarily be unexpected. To exclude the bills least
likely to be unexpected, we performed an additional analysis for elective
inpatient admissions (n = 2 149 893; defined as admissions with no claims from
an emergency department physician or a medical transport service) which only
included out-of-network billing by hospital-based physicians (diagnostic radiology,
anesthesiology, pathology, and critical care medicine), over whom the patient
would likely have limited choice.
Results
ED
Visits
Among
all 13 579 006 ED visits to in-network hospitals, 5 303 390 (39.1%) resulted in
an out-of-network bill (Table 1). The incidence of out-of-network
billing among ED visits increased from 32.3% in 2010 to 42.8% in 2016 (P < .001).
The potential financial responsibility associated with out-of-network billing
also substantially increased, from a mean (SD) of $220 ($420) in 2010 (median,
$107; interquartile range [IQR], $5-$300) to a mean (SD) of $628 ($865) in 2016
(median $482; IQR, 181-891). The potential financial responsibility among the
top decile of patients who received an out-of-network bill increased from $575
in 2010 to $1364 in 2016.
Out-of-network
billing for ED visits was particularly common for ambulance transport: 85.6% of
encounters with ambulance services resulted in an out-of-network bill to the
patient, with a mean (SD) potential financial responsibility of $244
($801); Table 2 presents the 10 most commonly
encountered specialties and eTable 1 in the Supplement presents all specialties. Of
patients receiving care from an emergency physician, 32.6% received an
out-of-network bill (mean [SD] potential responsibility, $396 [$382]), as did
nearly a quarter of patients receiving care from an internist (23.8%; mean
[SD], $186 [$308]) or anesthesiologist (22.8%; mean [SD], $568 [$855]).
Inpatient
Admissions
During
the entire study period, 37.0% of inpatient admissions to in-network hospitals
(2 019 922 of 5 457 981) resulted in at least 1 out-of-network bill, with the
incidence of out-of-network billing increasing from 26.3% in 2010 (159 609 of
607 160) to 42.0% in 2016 (397 447 of 947 111; P < .001) (Table 3). As for ED visits, the mean (SD)
potential financial responsibility substantially increased during the study
period, from $804 ($2456) in 2010 (median, $285; IQR, $30-$794) to $2040
($4967) in 2016 (median, $984; IQR, $325-$2084). In 2016, the top decile of
patients with out-of-network bills faced a potential liability of $4112 or
more.
Among
the physician specialties with the most frequent billing for inpatient care,
the incidence of out-of-network billing ranged from 0.8% for obstetrics and
gynecology (mean [SD] potential responsibility, $1228 [$3457], median, $293;
IQR, 91-1075; see Table 4 for 10 most commonly encountered
specialties and eTable 2 in the Supplement for all specialties) to 81.6%
for ambulance services (mean [SD] potential responsibility $424 [$2176];
median, $44; IQR, $0-$365).
Distribution
Across Hospitals
The
incidence of out-of-network billing for inpatient admissions across hospitals
followed a bimodal distribution (Figure). For approximately half (1606 of 3296)
of hospitals, the incidence was less than 10%. The incidence of out-of-network
billing for ED visits was less than 10% for approximately one-quarter (1002 of
4028) of hospitals. By comparison, more than 90% of inpatient admissions
resulted in an out-of-network bill at 500 hospitals (15.2% of all hospitals),
and more than 90% of ED visits were accompanied by an out-of-network bill at
942 hospitals (23.3% of all hospitals).
Subgroup
and Sensitivity Analyses
In a
subgroup analysis, the incidence of out-of-network billing was lower for
surgical admissions (30.9% vs 42.0%; P < .001; eTable 3 in
the Supplement), but the potential financial
liabilities were higher (mean [SD] liability $2406 [$6108] vs $914
[$1962]; P < .001).
The
sensitivity analyses performed to investigate potential mismeasurement of the
potential financial liability for cases where the estimated potential financial
liability was negative had qualitatively similar results to the main analysis
(eTable 4 and eTable 5 in the Supplement). Sensitivity analyses that included
emergency department visits where physician or ambulance service network status
was unknown also had qualitatively similar results to the main analysis
(eTables 6-9 in the Supplement). The analysis that was restricted to
out-of-network billing by hospital-based physicians for elective inpatient
admissions found a lower incidence overall of out-of-network billing (17.6% for
the study period), with the incidence increasing from 13.1% to 20.5% of
elective inpatient admissions during the study period (eTable 10 in the Supplement); by comparison, in the main analysis
the overall incidence of out-of-network billing was 37.0%, and the incidence of
out-of-network billing increased from 26.3% to 42.0% during the sample period.
For patients who received an out-of-network bill, this analysis found potential
financial responsibilities that were lower than in the main analysis (mean
[SD], $1190 [$1965]; median, $431; IQR, $85-$1557;main analysis mean [SD],
$1547 [$4382]; median, $667; IQR, $183-$1538).
Discussion
In a
national sample of US patients with private health insurance, the incidence of
out-of-network billing at in-network hospitals substantially increased between
2010 and 2016, from 32.3% to 42.8% of ED visits and from 26.3% to 42.0% of
inpatient admissions. Moreover, the potential financial consequences of
out-of-network billing in both settings nearly doubled during this period, and
the top 10% of patients faced liabilities of more than $1000 for ED visits and
more than $3000 for inpatient care. Sensitivity analyses suggested a lower
incidence of unanticipated out-of-network billing for elective inpatient
admissions, but showed a similar increase during the study period, with
potential financial liabilities for patients that were similar to those in the
main analysis. Overall, our findings suggest a growing risk to patients of
incurring burdensome unexpected out-of-network bills.
Our
study builds on previous work by characterizing the incidence and magnitude of
out-of-network billing for inpatient admissions and for physicians other than
emergency physicians. Previous studies11-13 have
found the incidence of out-of-network billing to be about 20% of ED visits,
although one of these studies did not measure incidence directly13;
by comparison, our estimate is 39%. The difference between these findings may
reflect differences in the geographic area or time periods studied. In
addition, some previous studies11,25only
considered out-of-network billing by the attending emergency physician; our
study, however, examined billing by all physician specialties and medical
transport services. A recent report using an alternative source of commercial
claims data (the Health Care Cost Institute) from 37 states and the District of
Columbia in 2016 found that the state-level incidence of out-of-network billing
for inpatient admissions ranged from 1.7% in Minnesota to 26.3% in Florida (the
report did not characterize the amount of financial responsibility).15
From a
policy perspective, a potential benefit of balance billing is that patients
have flexibility to choose to receive care from out-of-network physicians.
However, inherent to this benefit is patients’ awareness that balance billing
may occur and their willingness to pay the additional amount. Our findings are
notable because out-of-network billing was common among medical transport
services and hospital-based physicians (eg, emergency physicians, radiologists,
and anesthesiologists) providing care at in-network hospitals. In such
circumstances, patients could easily assume that the entire hospital team is in
network and thus the balance billing may come as a surprise. Further, in these
contexts, patients may have limited ability to choose an in-network physician
or ambulance.
Even
modest unexpected bills can create financial stress for patients. A recent
survey found that 4 in 10 Americans would be unable to pay an unexpected
expense of $400 without selling something or borrowing money.27 The
median amounts for which patients in our study were sent balance bills ($984
for inpatient admissions and $482 for emergency visits in 2016) exceed that
level. Further, the top decile of patients with out-of-network bills faced
substantial potential financial responsibility: $4112 for inpatient admissions
and $1364 for ED visits.
Because
out-of-network bills most commonly originated from clinical services (ie,
medical transport, emergency medicine) about which patients have little choice,
policy solutions centered on disclosure and consent at the point of care may
not meaningfully address a large part of the problems patients face.28Policies
that limit the ability of physicians and medical transport services to balance
bill patients—for example, by shifting some portion of the patient’s
responsibility to insurers—offer stronger protection. Even in the absence of
such interventions, greater understanding of variations in out-of-network
billing across hospitals may be helpful in identifying facilities whose
financial strategy involves heavy reliance on out-of-network physicians to
staff core services (ie, facilities where out-of-network billing is extremely
common), which may allow insurers and other parties to better inform patients
about the potential financial consequences of receiving care at these
facilities.
Limitations
Our
study has limitations. First, unexpected out-of-network billing could not be
isolated, although as previously noted, out-of-network billing could easily be
unexpected among patients who present at an in-network hospital, and previous
work has found that most out-of-network billing in the inpatient setting is
involuntary.29 Second,
the data did not include information on the proportion of balance-billed
amounts that patients actually paid. Physicians and medical transport services
may be willing to negotiate the amount owed, although there are limited data on
how often patients are able to negotiate lower payments. One study found that
only 19% of patients attempted to negotiate balance-billed amounts, and
slightly more than half of patients who did so were successful in obtaining any
reduction in the amount owed.30 Moreover,
these negotiations may not happen before the matter is sent to collections,
which could jeopardize the patient’s credit rating. Third, we excluded visits
to out-of-network hospitals, where unexpected out-of-network billing would be
harder to measure because patients may have specifically chosen the hospital
and may have less expectation that physicians there would be in-network.
Fourth, our analysis excluded approximately 20% of visits where the network
status of at least 1 physician or medical transport service could not be
determined, although subsequent sensitivity analyses including these visits
showed qualitatively similar results. Fifth, our analysis may underestimate the
extent of out-of-network billing, as it did not account for billing from
sources other than physicians and medical transport services (eg, laboratory
charges). Sixth, in estimating the potential financial liability, we used the
national mean paid in-network for a given service, which while accurate, could
underestimate or overestimate the potential financial liability for any
individual patient. In addition, the data were limited to a sample of patients
from a single private insurer.
Conclusions
Our
findings appear to support current efforts to strengthen legislative
protections against out-of-network billing in circumstances that are likely to
involve surprise bills.
Article
Information
Accepted for Publication: June 21, 2019.
Corresponding Author: Eric Sun, MD, PhD,
Department of Anesthesiology, Pain and Perioperative Medicine, H3580, Stanford
University Medical Center, Stanford, CA 94305 (esun1@stanford.edu).
Published Online: August 12, 2019. doi:10.1001/jamainternmed.2019.3451
Author Contributions: Dr Sun had full
access to all of the data in the study and take responsibility for the
integrity of the data and the accuracy of the data analysis.
Concept and design: All authors.
Acquisition, analysis, or interpretation of data: Sun,
Mello, Moshfegh.
Drafting of the manuscript: Sun, Moshfegh.
Critical revision of the manuscript for important intellectual
content: Mello, Moshfegh, Baker.
Statistical analysis: Sun, Moshfegh.
Obtained funding: Sun.
Administrative, technical, or material support: Baker.
Supervision: Sun.
Conflict
of Interest Disclosures: Dr Sun reported grants from the National
Institute on Drug Abuse during the conduct of the study; personal fees from the
Mission Lisa Foundation and personal fees from Egalet, Inc outside the
submitted work. Ms Moshfegh reported grants from the Agency for Healthcare
Research and Quality during the conduct of the study. Dr Baker reported a grant
from the National Institute for Health Care Management outside the submitted
work, personal fees from the National Institute for Health Care Management,
personal fees from Blue Cross and Blue Shield of California, personal fees from
Blue Cross and Blue Shield of Florida, and personal fees from Dignity Health
outside the submitted work. No other disclosures were reported.
Funding/Support: Funding
for this study was provided to Dr Sun from the National Institute on Drug Abuse
(K08DA042314) and to Ms Moshfegh from the Agency for Healthcare Research and
Quality (T32HS026128).
Role of the Funder/Sponsor: The funders had no
role in the design and conduct of the study; collection, management, analysis,
and interpretation of the data; preparation, review, or approval of the
manuscript; and decision to submit the manuscript for publication.
Additional
Information: Data for this project were accessed using the Stanford
Center for Population Health Sciences (PHS) Data Core. The PHS Data Core is
supported by a National Institutes of Health National Center for Advancing
Translational Science Clinical and Translational Science Award (UL1 TR001085)
and from Internal Stanford funding.
Disclaimer: The content is solely the responsibility
of the authors and does not necessarily represent the official views of the
National Institutes of Health or the Agency for Healthcare Research and
Quality.
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