'Surprise' medical bills, explained in 5 charts

By Jackie Kimmell, Senior Analyst

More than 50% of U.S. residents said they have been surprised by a medical bill they had expected their health insurance to cover, according to an AmeriSpeak survey from NORC at the University of Chicago released Thursday.

For the survey, researchers between Aug. 16 and 20 interviewed a nationally representative sample of more than 1,000 English-speaking U.S. adults ages 18 and older. Overall, researchers found 57% of respondents said they had been surprised by a medical bill they had thought their health insurance would cover.

1. Surprise bills cover all types of services

A slight majority of patients were most surprised by bills for physician services, although laboratory tests and facility fees closely followed.

2. Who's to blame? Patients spread the responsibility between payers and providers.

When asked who was responsible for the surprise bills, more than 80% of patients thought insurers and hospitals were very or somewhat responsible. Majorities of respondents also said physicians or pharmacies were very or somewhat responsible.

3. Out-of-network bills are often the most surprising—and difficult to pay

Among the respondents in the NORC survey who received surprise medical bills, 20% said the bills stemmed from treatment provided by physicians who were not included in their health plans' networks.

A report from the Brookings Institution's Center for Health Policy and the USC Schaeffer Center for Health Policy and Economics found that one-third of adults who are struggling to pay their medical bills say the problem stemmed from out-of-network care.

This is often because patients didn't expect an out-of-network claim: 70% of those having trouble paying their out-of-network bills were unaware that the care was out-of-network.

4. Out-of-network claims are common, even at in-network facilities, and especially when they include the ED

Part of this confusion over in- and out-of-network claims may stem from the fact that many out-of-network providers work and bill at in-network facilities.

A recent analysis by the Kaiser Family Foundation of claims in large employer health plans found that 15.4% of claims for inpatient admissions included an out-of-network claim, even when the patient used an in-network facility. The same study found that 5.3% of in-network outpatient service claims included a similar out-of-network claim.

Emergency department visits are even more likely to include a surprise out-of-network claim. The same study found that a visit was 12.1% more likely to include an out-of-network claim when it also included an ED claim. Notably, this pattern was the same facilities that were in-network for the patient (where claims were 11.7% more likely to include an out-of-network claim if the patient had visited the ED).

5. Many out-of-network claims arise from a scarcity of in-network ED physicians

Many of these surprise out-of-network claims are for a physician charge. A study in the New England Journal of Medicine conducted by Yale University economists found that, of the 99.35% of ED visits they analyzed that occurred at in-network facilities, 22% involved out-of-network physicians.

This reflects the reality that, in many EDs where the facility is in-network for the patient, many of the physicians who work there may not be. The Center for Public Policy Priorities, an Austin-based think tank, analyzed data from the state's three largest payers, and found that, among the hospitals included in their networks, 18 to 63% have no in-network emergency physicians. There are more than 300 hospitals in Texas where the hospital is in-network, but not a single doctor is for at least one of three major payers studied.

(Kacik, "Transformation Hub," Modern Healthcare, 8/30; Japsen, Forbes, 8/30; Spitzer, Becker's Hospital Review, 8/30; NORC release, 8/30; NORC survey, accessed 8/30).

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