Press "Enter" to skip to content

HCCI Analysis: How Common is Out-of-Network Billing?

This analysis from the Health Care Cost Institute (HCCI) looks at how often services are delivered by an out-of-network provider at an in-network facility across several specialties, by state, using HCCI claims data for individuals with employer-sponsored insurance in 2017.

Specifically, they examined visits for anesthesia, behavioral health, cardiovascular, emergency, pathology, radiology, and surgery services delivered by providers of the same specialty in 2017. They grouped all claims for the same type of service delivered to the same patient on the same day together into a “visit”. And then determined the share of those visits that included at least one claim for an out-of-network provider. They then estimated the potential “surprise bill”, by calculating the difference between the charges and allowed amounts on the out-of-network claims included in the visit.

Key Findings:

The frequency of out-of-network bills varies by type of service. In 2017, nationally:

  • 16.5% of visits with emergency room services had an out-of-network claim from an emergency medicine specialist.
  • 12.9% of visits with lab/pathology services had an out-of-network claim from a pathologist.
  • 8.3% of visits with anesthesiology services had an out-of-network claim from an anesthesiologist.
  • 6.7% of visits with behavioral health services had an out-of-network claim from a behavioral health provider.
  • 4.2% of visits with radiology services had an out-of-network claim from a radiologist.
  • 2.1% of visits with surgical services had an out-of-network claim from a surgeon.
  • 2.0% of visits with cardiovascular services had an out-of-network claim from a cardiovascular specialist.

Variation across states differs by type of service:

  • Pathology and emergency services had the largest variation.
  • Cardiovascular and surgery services had the the smallest variation.

Potential surprise bills for surgery visits are orders of magnitude larger than for other types of service.

  • Nationally, the average potential surprise bill associated with an inpatient surgery was $22,248; outpatient surgery was $8,493.

Read more:

Be First to Comment

Leave a Reply