Affordability of healthcare has often been cited as a top issue for patients, with many viewing serious illness less frightening than the cost. Proponents of our current system say that since most people get their insurance from employers, that shouldn’t be a top concern for most.
But surprise or unintentional out-of-network costs even for those who have employer insurance continue to be a problem. (California protects some insured patients from high medical bills from out-of-network providers if they receive care at an in-network facility.)
In an analysis by the Kaiser Family Foundation, patients can face higher, sometimes much higher, out-of-pocket costs when they receive care from providers that are not in their plans’ provider networks.
Under the Affordable Care Act, private health plans are required to have a maximum limit on cost-sharing payments for a year, but generally this only applies to services from in-network providers.
Patients can be sometimes shocked at the bills they get from their insurers. An insurance plan may have somewhat higher cost-sharing for services from out-of-network providers. Insurers may also ask patients to pay any difference between what the plan reimburses and the amount that the provider charges for its services, and can expose patients to very high out-of-pocket costs.
According to the KFF analysis, nearly one in five inpatient admissions includes a claim from an out-of-network provider. The share of inpatient admissions with a claim from an out-of-network provider remains significant even when patients use in-network facilities for care.
For inpatient admissions, those that include an emergency room claim are much more likely to include a claim from an out-of-network provider than admissions without an emergency room claim. This is true whether or not patients use in-network facilities.
Significant shares of outpatient service days that include a claim for psychotherapy or therapeutic psychiatric services include a claim from an out-of-network provider. This raises questions about the availability and quality of mental health service providers within health plan networks.
Outpatient service days with a facility claim that include an anesthesiology claim (for example, outpatient surgeries) are more likely to include a claim from an out-of-network provider. In addition, outpatient service days with a facility claim that include a pathology claim (i.e., for lab work) are more likely to include a claim from an out-of-network provider.
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