Patients shoulder a significant financial impact when they unwittingly go out of network for care—which can happen during inpatient stays when they discover that not every member of their medical team takes their insurance.
As the CMS releases more data about what hospitals charge for common procedures—and hospital retort that the charges are only list prices—a new study attempts to answer the question of what patients actually pay.
And what it found was that even patients who think they're following their health plan's rules may find still themselves on the hook for unexpected costs.
Dr. Kelly Kyanko, an instructor in the section on value and effectiveness at NYU Langone Medical Center, points to the example of an obstetrical patient whose baby needs to go to the neonatal intensive-care unit after delivery. When the bill comes, the patient discovers that the neonatologist doesn't take her insurance—and neither did the anesthesiologist who administered her epidural.
“The onus is really on the patient in the current system,” said Kyanko, whose study suggested that about 3 million patients in the U.S. are hit with unexpected out-of-network charges. “We were surprised by our numbers. It's not a rare occurrence.”
The study, published in the June issue of the Health Services Research Journal, builds upon a prior study Kyanko and colleagues conducted that looked at 7,812 individuals with private insurance plans. The findings showed that about 8% of U.S. patients currently go out of network for care, and of those, 40% do so involuntarily.
The latest study adds 26 in-depth patient interviews to characterize the experiences of patients who involuntarily went out of network.
“It was mostly an inpatient issue; it was mostly a system-level problem,” Kyanko said, adding that the findings go against the current conventional wisdom that out-of-network care is typically elective. What struck her, she said, is that patients really tried to adhere to the plan's rules. “Education was not a predictor to experiencing out of network care.”
When patients go out of network, their health plan will typically try to negotiate a rate that is “usual and customary” for the services provided. If the hospital doesn't like the offer, state laws and insurance contracts dictate whether it can engage in “balance billing,” or go after a patient for charges not covered by the insurer, said Monica Wilkinson, senior counsel in the healthcare group at law firm Dykema Gossett.
“There has been litigation in the past to deal with that issue,” she said.
It's also difficult, if not impossible, for patients to get a complete estimate of charges before treatment. Even when patients make an effort, Kyanko found that some physicians create confusion by saying they “accept” certain insurance when they're actually out of network.
“Part of the problem is that patients don't know the proper questions to ask the provider,” Wilkinson said. “It's very difficult to be an informed consumer the way it's set up at this point.”
The Patient Protection and Affordable Care Act does address out-of-network emergency care, but “emergency care is not always in the emergency room,” Kyanko said.
She pointed to other solutions that hospitals can implement such as requiring physicians to take the same insurance as the facilities in which they have privileges or holding patients harmless for involuntarily going out of network.
Follow Beth Kutscher on Twitter: @MHbkutscher
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