Yale Researchers: In-Network Patients Often Hit With Out-of-Network Bills

Anesthesiologists, pathologists, radiologists, and assistant surgeons charge the higher rate
Robert Calandra

Zack Cooper

A new study from researchers at Yale University found that patients receiving care at in-network hospitals still face a major risk of getting billed for out-of-network services.

The study, published ahead of print this week on the Health Affairs web site, used 2015 data from a large commercial insurer.  The research team led by Associate Professor Zack Cooper found that at in-network hospitals, 11.8% of anesthesiology care, 12.3% of pathology work, 5.6% of radiology claims, and 11.3% of cases involving an assistant surgeon were billed out-of-network.  

Billing out-of-network allows specialists to negotiate artificially high in-network rates, according to Cooper and his colleagues. The practice is more prevalent in highly concentrated hospital and insurance markets and at for-profit hospitals.

Cooper and his team calculated that if specialists were not permitted to bill out-of-network, it would lower their payments from privately insured patients by 13.4%, and reduce health care spending for people with employer-based insurance by 3.4%, or roughly $40 billion annually, according to the study.

The Yale researchers said that the ability to bill out-of-network for patients  “undercuts the functioning of health care markets, raises health care costs, and exposes patients to significant financial risk.”

Congress is considering several bills that would limit "surprise" out-of-network billing. One possibility is an arbitration process to settle the amount of bill. Another would tie out-of-network bills to in-network payment rates.