Washington, D.C. – Many patients receiving care from out-of-network providers or specialists in Oregon face exorbitant charges for medical services, according to a new report from America’s Health Insurance Plans (AHIP). Health plans and patients routinely receive charges from out-of-network providers that range from 176 - 721 percent of the amount paid by Medicare for the same services.
The report presents the most comprehensive analysis to date on out-of-network charges based on FAIR Health’s private health insurance database of more than 18 billion claims. The findings underscore the affordability challenges facing millions of Americans, particularly when patients face "surprise" bills from out-of-network doctors and clinicians.
"Improving access to health care requires us to fundamentally address the barriers to affordability, including the excessive prices charged for medical services," AHIP President and CEO Marilyn Tavenner said. "This latest report demonstrates the serious cost pressures facing consumers who want affordable access to care and the added financial burden caused by soaring out-of-network medical bills."
Highlights of charges in Oregon include:
- Ultrasonic guidance for biopsies incurred excess charges averaging more than 600 percent of the Medicare fee.
- Some patients seeking emergency care faced potential excess charges averaging more than 400 percent of the Medicare fee.
- Patients that underwent an hour of chemotherapy saw potential charges averaging more than 300 percent of the Medicare fee.
- Potential excess charges for critical care averaged more than 200 percent of the Medicare fee.
These steep costs underscore the value of health plans' provider networks. By selectively contracting with credentialed providers, health plans ensure consumers have access to a range of doctors and clinicians who have a track record of delivering high-quality care. Patients also see measurable savings when they visit contracted providers.
Yet when providers choose not to participate in a health plan's network or do not meet requirements for participation, consumers have little protection against physicians who "balance bill" or charge the cost difference for a particular service.
Health plans have worked with stakeholders across the health system to identify ways to mitigate surprise out-of-network charges. This includes:
- Providing consumers with clear, easy-to-access information on in-network providers and cost estimates through provider network directories and cost calculators;
- Requiring in-network hospitals that employ out-of-network providers to provide detailed disclosures of those specialists, including an estimate of charges and patient liability prior to rendering services;
- Promoting greater transparency from providers and specialists regarding their network status, including disclosure from out-of-network providers regarding their fees and costs;
- Strengthening financial protection for consumers by imposing limits on balance billing from out-of-network providers; and
- Advancing state laws to protect consumers from surprise out-of-network charges.
To view the full report, click here.
