A Kaiser Family Foundation analysis of medical bills shows that 15% of patients with large-employer coverage were billed for out-of-network costs even though they were admitted to an in-network facility.
The analysis, released by the healthcare policy nonprofit Aug. 13, also found that in-network claims that include an emergency room visit are more likely to include an out-of-network charge.
Patients seek out-of-network care on their own for a number of reasons, such as personal preference, convenience or familiarity. Sometimes a network may have few options for certain services.
Out-of-network selection may also be inadvertent, Kaiser said. For instance, when an in-network hospital charges separately for an anesthesiologist who may be out-of-network. A separate Kaiser report from 2016 showed that 7 in 10 people who received unaffordable out-of-network costs were unaware that the provider was not in their network at the time they received care.
Kaiser's analysis also showed that psychological or substance abuse care were billed as out-of-network services 33.5% of the time. This is more than 10% higher than the next closest category of care, which was surgical.
Charges for out-of-network care can be dramatically higher than in-network care. According to Aetna Inc.'s website, a member may spend an extra $505 when visiting an out-of-network doctor compared to an in-network one. Insurers will rarely cover out-of-network costs in full, which means the additional cost is the responsibility of the member.
The Affordable Care Act limits how much enrollees in private plans are responsible for cost-sharing expenses such as deductibles, coinsurance, and copays. But these limits are typically only for in-network providers. Federal regulations restrict insurers from requiring a larger co-pay from patients for out-of-network costs for most emergency services. The rules do not, however, prevent out-of-network providers from charging patients for the portion of the bill that an insurance company does not cover. This is referred to as balance billing, according to Kaiser.
Several states have implemented regulations to address what they have dubbed surprise medical bills when out-of-network care occurs. California, for instance, passed legislation in 2016 that protects patients who go to in-network hospitals, labs or imaging centers, from receiving out-of-network bills. The law also shields patients from collections or negative credit because of these bills. New York passed similar legislation that went into effect in 2015.
Kaiser looked at claims from the Truven Health Analytics MarketScan Commercial Claims and Encounters Database, a large-employer database. All the claims were from 2016 and totaled nearly 20 million people, according to the analysis.