Survey of Charges Billed by Out-of-Network Providers: A Hidden Threat to Affordability
January 2013

View Full Report

Overview

Report Infographics


       

 

About the Survey

This report provides a snapshot, state-by-state, of exorbitant charges billed by out-of-network physicians in the 30 largest states by population. It is designed to illustrate the value of provider networks and a growing problem faced by consumers who want affordable, meaningful, access to out-of-network providers.

The information was collected in a survey of AHIP member plans. The plans were asked to provide the three highest billed charges in 2011 and their corresponding zip codes from non-participating providers for each of the 24 CPT procedure codes within the 30 most populous states. This report updates a similar survey report done by AHIP and Dyckman & Associates, LLC in 2009.

Highest Reported Out-of-Network Provider Charges Compared to Medicare Payments for 10 Common Medical Procedures

Highest Reported Out-of-Network Provider Charges Compared to Medicare Payments for 10 Common Medical Procedures 

Protecting consumers from runaway charges billed by some out-of-network physicians is an important policy issue at a time of major economic challenges and a national debate surrounding the affordability of health care. 

 

When patients receive care out-of-network, such as during an emergency or when a physician refuses to join a network, there is no limit to what providers can charge for these services. 

 

Nationally, approximately 88% of all claims were paid on an in-network basis in 2011—12% of claims were paid out-of-network.

Pie 
  • Figure 4Comparison of Highest Billed Charge as a Percent of Medicare Fee for Critical Care, First 30–74 Minutes 
  • Figure 2Comparison of Highest Billed Charge as a Percent of Medicare Fee for Tissue Exam by Pathologist 
  • Figure 3Comparison of Highest Billed Charge as a Percent of Medicare Fee for Subsequent Hospital Care