Nearly 1 in 5 Inpatient Admissions Includes a Claim From an Out-of-Network Provider

Almost 18% of inpatient admissions include a claim from an out-of-network provider, according to a new analysis from the Kaiser Family Foundation.

The analysis, which looked at medical bills from large employer plans from 2016, also found that 7.7% of outpatient service days—combined outpatient services from a single day—included a claim from an out-of-network provider. Outpatient service days that included a claim from a facility provider, such as an emergency department (ED) or an outpatient hospital, were slightly more likely (9.2%) to include an out-of-network claim.

Out-of-network claims can arise for several reasons. Patients may prefer a provider outside of their network or their network may have few in-network options for certain types of services, such as mental health care. In other cases, patients may not be in a position to choose an in-network provider, for example, in emergency situations.

There are also instances where a patient receives care from an out-of-network provider while being treated at an in-network hospital or surgical center, or an in-network provider refers a patient to an out-of-network provider for services such as laboratory testing. These instances have been coined “surprise medical bills.”

“In many instances, it is doubtful that enrollees could reasonably anticipate or control their use of out-of-network providers,” wrote the authors of the analysis.

Read more about billing for unavoidable out-of-network care.

When receiving care from an out-of-network provider, patients often face significantly higher out-of-pocket costs. These out-of-network services may not be covered at all in some cases. In others, patients may have higher cost-sharing amounts or they may be asked to pay the difference between what the plan reimburses and what the provider charges for the services.

The analysis found that patients using in-network facilities were still subject to out-of-network claims, particularly for inpatient admissions (15.4%). Among inpatient admissions, those that include an ED claim are more likely to experience claims for an out-of-network provider (27.2% vs 15.1%). The same was seen for outpatient service days that included an ED claim (19.5% vs 7.5%).

Those seeking inpatient treatment for psychological reasons or substance use are most likely to receive an out-of-network claim (33.5%), followed by those seeking surgical treatment (20.3%), medical treatment (18.9%), and childbirth or newborn care (11.1%).

According to the authors of the analysis, several policies have been adopted to protect patients from these surprise medical bills. A federal law requires health plans to apply in-network cost sharing when patients use out-of-network providers in emergency services. However, this law does not protect patients if the out-of-network providers bill patients directly for additional charges.

“Constructing policies to help consumers exposed to surprise medical bills is complex and involves several difficulties,” they wrote. For example, there are multiple parties involved in instances that result in out-of-network charges. Also, states can pass laws that regulate health insurers and providers, but they can’t regulate the conduct of private employer plans that are self-funded.