Patients May Still Get a Surprise Bill After an In-Network ER Visit, Study Finds [View all]

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Patients who get emergency care at a hospital in their insurance network have nearly a 1 in 4 chance of being treated by an out-of-network ER physician who may send a “surprise” bill, according to an analysis in the New England Journal of Medicine.

The study, by two Yale University economists, is one of the first to quantify the surprise-bill issue that has caused patient uproar and stoked friction between ER doctors and insurers.

The situation arises because hospital-based specialists—particularly radiologists, anesthesiologists and ER physicians—are often employed by outside companies that negotiate separately with insurers. As insurance networks narrow, more patients have complained of being blind-sided by bills—from hundreds to thousands of dollars—from out-of-network doctors they had no choice in seeing.

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The researchers analyzed claims data from a large commercial insurer that included more than 2.2 million ER visits in all 50 states. Although more than 99% of the visits occurred at in-network hospitals, 22% involved out-of-network physicians. The study also revealed wide geographic variations. In McAllen, Texas, nearly 90% of ER visits involved out-of-network doctors, while in Boulder, Colo., and South Bend, Ind., nearly none did.

Under the Affordable Care Act, insurers must pay a “reasonable amount” when their plan members receive emergency care from out-of-network doctors and hospitals, and can’t require patients to pay a higher share of the amount than they would for in-network services. But the law gives insurers latitude for determining that amount, and allows out-of-network providers to bill patients for the balance.

The Yale researchers weren’t able to determine how many out-of-network physicians pressed patients to pay the difference between their full charges and what insurance paid—a practice known as “balance billing.” But the potential for extra cost was considerable. According to the claims data, the out-of-network ER physicians charged, on average, nearly eight times what Medicare pays for the same services, and nearly twice the average in-network reimbursement rate. One patient faced a potential balance bill of $19,603, the study found.

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http://www.wsj.com/articles/patients-may-still-get-a-surprise-bill-after-an-in-network-er-visit-study-finds-1479333600