Nearly 20% of inpatient admissions include out-of-network charge

Les Masterson

Aug. 14, 2018

Dive Brief:

• A new Kaiser Family Foundation report found that almost one in five inpatient admissions in large employer health plans includes a claim from an out-of-network provider.  
• Even when patients use in-network facilities, they often face claims from out-of-network providers. That's true especially for emergency room claims, according to the report.
• Members who receive outpatient mental health services are significantly more likely to have a claim from an out-of-network provider, KFF said.

Dive Insight:

Surprise billing, also called balance billing, is an issue that continues to confront patients despite federal and state regulations. Even patients who make sure the facility is in-network can get whacked with out-of-network charges based on who cares for them at the facility.  

Surprise billing can leave patients with medical bills beyond their means. A 2016 KFF survey reported that nearly 70% of people who couldn't afford out-of-network bills said they didn't know the provider was out of network when they received care.

The study authors analyzed 2016 claims for nearly 20 million people. The claims represented almost one-quarter of the 85 million people in the large group market.

The review found that 27% of admissions with an emergency room claim includes an out-of-network charge. Only 15% of in-patient visits that didn't include an ER visit wound up with out-of-network claims.

"Patients in emergency situations have limited ability to control the care they receive and from whom they receive it. Even when the facility is in-network, the professional services may not be and the patient often is not in a position to direct their care," according to the report.

The study also found that one-third of in-patient psychological or substance abuse claims includes an out-of-network charge. That percentage compares with surgical (20%), medical (19%) and children and newborn (11%).

The report suggested the reason for more out-of-network claims for psychological and or substance abuse is because of fewer in-network facilities or professional for those services.

KFF added that members with anesthesia and pathology claims are more likely to have an out-of-network claim regardless as to whether they get services from an in-network facility. "In many instances, it is doubtful that enrollees could reasonably anticipate or control their use of out-of-network providers," the report said.

KFF's report findings mirror a Health Affair study that found one-fifth of all hospital inpatient admissions that originated in the ER, 14% of outpatient ER visits and 9% of scheduled inpatient admissions led to surprise medical bills.

Though federal law requires health plans to apply in-network cost sharing when members use out-of-network providers in emergency services and some states have strengthened laws against surprise billing, many people still get hit with out-of-network charges directly from providers.

In fact, an Altarum report in November awarded only Maine and New Hampshire an A on healthcare price transparency. Maryland and Oregon got a B while Colorado and Virginia received a C. Every other state failed.

But some patients are fighting back against surprise billing.

"A lot of consumers don't understand how insurance works, and particularly these days with high-deductible health plans becoming more and more common, a lot of people are getting bills they don't understand," Akshay Gupta, co-founder and executive partner of CoPatient, a company that helps consumers understand and resolve their medical bills, recently toldHealthcare Dive. "People that come to us are often quite distraught."

https://www.healthcaredive.com/news/nearly-20-of-inpatient-admissions-include-out-of-network-charge/529977/