To explore whether a small group of providers are responsible for most out-of-network billing, or if the practice is widespread, the Health Care Cost Institute (HCCI) examined the distribution of out-of-network claims among individual clinicians in 2017. They identified visits for emergency medicine, pathology, radiology, anesthesiology, behavioral health, and cardiovascular services performed by providers with the same specialty. Their sample included 13.8 million visits by over 35 thousand unique providers. They then calculated the percent of providers with at least 1 out-of-network claim, as well as the percent of out-of-network claims by provider billing at least once out of network.
Their analysis found substantial variation in the prevalence of providers who billed out of network among six common provider specialties. In every specialty, more than half of the sample’s providers never billed out of network. And even among providers who did bill out of network, the plurality to vast majority – depending on the specialty – tended to bill out of network infrequently (less than 10 percent of the time). There were, however, some providers who almost exclusively billed out of network (more than 90 percent of the time), most notably in the pathology specialty. Consistent with previous work, these findings show that out-of-network billing practices are not common across providers.