Analysis: For Patients with Large Employer Coverage, About 1 in 6 Hospital Stays Includes an Out-of-Network Bill
Emergency Room, Mental Health and Substance Abuse Admissions Most Likely to Generate Out of-Network Claims
A new Kaiser Family Foundation analysis of medical bills from large employer plans finds that a significant share of inpatient hospital admissions includes bills from providers not in the health plan’s networks, generally leaving patients subject to higher cost-sharing and potential additional bills from providers.
Almost 18 percent of inpatient admissions result in non-network claims for patients with large employer coverage. Even when enrollees choose in-network facilities, 15 percent of admissions include a bill from an out-of-network provider, such as from a surgeon or an anesthesiologist. These bills potentially expose enrollees to high out-of-pocket costs if these providers charge enrollees more than their plans pay for services. This is typically referred to as “balance billing,” and can result in a “surprise” medical bill if a patient did not anticipate receiving care from an out-of-network provider. Health insurance plans also typically require higher patient cost-sharing for out-of-network claims.
For both inpatient admissions and outpatient services, use of an emergency room is associated with higher rates of out-of-network bills. Treatments for mental health and substance abuse also have a much higher chance of including a claim from an out-of-network provider, potentially reflecting difficulty in finding a participating provider.
The issue brief is available on the Peterson-Kaiser Health System Tracker, a partnership between the Peterson Center on Healthcare and the Kaiser Family Foundation that monitors the U.S. health system’s performance on key quality and cost measures.