August 14, 2019

The number of U.S. patients who were billed for out-of-network care received at in-network hospitals rose between 2010 and 2016—and the costs of those bills increased, as well—according to a study published Monday in JAMA Internal Medicine.  

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The study comes amid efforts in Congress to crack down on so-called "surprise" medical bills, which typically stem from patients receiving care from providers who are not in their health plans' networks at hospitals or other facilities that are in-network. The Senate is slated to vote on legislation to address surprise medical bills when lawmakers return from the chamber's current recess, The Hill reports.

Study finds increase in out-of-network bills

For the study, Stanford University researchers analyzed health insurance claims for about 13.6 million ED admissions and 5.5 million inpatient admissions among patients with private health insurance between 2010 and 2016.

The researchers found that four in 10 patients received an out-of-network medical bill after visiting an ED or being admitted to a hospital in 2016—an increase when compared with 2010.

Specifically, the researchers noted that the proportion of ED visits to in-network hospitals that resulted in out-of-network bills increased from 32.3% in 2010 to 42.8% in 2016. Similarly, the proportion of inpatient hospital admissions at in-network hospitals that resulted in out-of-network bills increased from 26.3% in 2010 to 42% in 2016.

The researchers also found that the average cost of out-of-network bills increased over that time period. According to the study, the average cost of an ED-related out-of-network bill was $628 in 2016, up from $220 in 2010. The average cost of an out-of-network bill for an inpatient admission was $2,040 in 2016, up from $804 in 2010.

Among inpatient admissions, certain specialties were more likely to result in out-of-network medical bills, the researchers found. According to the study, anesthesiology, emergency medicine, internal medicine, and radiology were among the specialties most likely to result in a surprise bill. For example, the researchers found that about one-third of patients treated by emergency physicians at in-network hospitals received out-of-network bills, while more than one in five patients treated by an internist or anesthesiologist received an out-of-network bill.

The biggest source of out-of-network bills, however, were ambulance rides, according to the study. About 86% of patients in 2016 faced surprise bills after taking an ambulance to the ED, the researchers found. They noted that the average cost of surprise bills for ambulance rides in 2016 was $244.

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According to Modern Healthcare's "Transformation Hub," the study reinforces previous research that found patients are increasingly facing surprise bills when they unknowingly receive care from out-of-network providers.

"Our findings are notable because out-of-network billing was common among medical transport services and hospital-based physicians … providing care at in-network hospitals," the researchers wrote. They added, "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."

According to Robert Steinbrook, editor at large of JAMA Internal Medicine and an adjunct professor at Yale University School of Medicine, patients often receive surprise bills after "an emergency," when "a patient is often unable to choose the ED, the physicians, or the ambulance service" they use. In other cases, "a patient may seek routine in-network care at an inpatient hospital or outpatient facility, only to later find out that in-network physicians were not available to care for them," Steinbrook added.

However, the researchers said one limitation of the study is that they could not determine how many of the surprise bills truly were a surprise to patients. The researchers noted that, in some cases, might have been aware of the pending out-of-network charge. But, regardless of whether the bills patients expect or not, "[t]he amount of money involved can be a significant burden for many patients," Eric Sun, lead author of the study and a researcher at Stanford University Medical Center, said (Hellmann, The Hill, 8/12; Rapaport, Reuters, 8/12; Livingston, "Transformation Hub," Modern Healthcare, 8/12, Owens, "Vitals," Axios, 8/13).

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