New Report Finds Patients Facing Exorbitant Charges For Out-of-Network Services

posted by Clare Krusing

on September 30, 2015

For Immediate Release

Washington, D.C.  For patients receiving care from out-of-network providers or specialists, many face exorbitant charges for medical services — on average 300 percent — compared to Medicare reimbursement for the same treatment or procedure, according to a new report from America’s Health Insurance Plans (AHIP). The findings underscore the affordability challenges facing millions of Americans, particularly when patients face “surprise” bills from out-of-network doctors and clinicians.

The report presents the most comprehensive analysis to date on out-of-network charges based on FAIR Health’s private health insurance database of more than 18 billion claims from all 50 states. The findings show that health plans and patients routinely receive charges from out-of-network physicians that range from 118 – 1,382 percent of amounts paid by Medicare for the same services.

“Improving access to health care requires us to fundamentally address the barriers to affordability, including the exorbitant prices charged for medical services,” AHIP President and CEO Marilyn Tavenner said. “This latest report demonstrates the serious cost pressures facing consumers who want affordable access to care and the added financial burden caused by excessive out-of-network medical bills.”

Key findings from the report include:

  • In New Jersey, charges for ultrasonic guide for biopsy averaged more than 1,200 percent of the Medicare fee for the same procedure.
  • Patients that underwent low back disc surgery in New York faced potential excess charges averaging more than 1,100 percent of the Medicare fee.
  • Some patients seeking emergency care in Florida faced potential excess charges averaging more than 700 percent of the Medicare fee.
  • Knee surgeries incurred potential excess charges averaging more than 500 percent of the Medicare fee for patients in Rhode Island.

These exorbitant charges underscore the value of health plans’ provider networks. Health plans develop provider networks to improve quality and make health care more affordable for consumers. By selectively contracting with credentialed providers, health plans ensure consumers have access to a wide-range of providers and clinicians, and patients see measurable savings when they visit contracted providers. Yet when providers choose not to participate in a health plan’s network or do not meet requirements for participation, consumers have little protection against physicians who “balance bill” or charge the cost difference for a particular service.

Health plans have worked with stakeholders across the system to identify ways to mitigate “surprise” out-of-network charges. This includes:

  • Providing consumers with clear, easy-to-access information on in-network providers and cost estimates through provider network directories and cost calculators;
  • Requiring in-network hospitals that employ out-of-network providers to provide detailed disclosures of those specialists, including an estimate of charges and patient liability prior to rendering services;
  • Promoting greater transparency from providers and specialists regarding their network status, including disclosure from out-of-network providers regarding their fees and costs;
  • Strengthening financial protection for consumers by imposing limits on balance billing from out-of-network providers; and
  • Advancing state laws to protect consumers from surprise out-of-network charges.

To view the full report, click here.


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