An article written in Modern Healthcare describes the surprising frequency with which in-network hospital admissions result in at least one out-of-network claim. About 1 in 7 patients receive unexpected out-of-network bills when obtaining inpatient care at an in-network hospital. The frequency of this occurrence varies by state, happening 26.3% of the time in Florida and 1.7% in Minnesota. Anesthesiology, a service that oftentimes negotiates contracts with payers separately from the hospital, accounted for the largest amount of out-of-network claims at 16.5%.
Patients are admitted to in-network hospitals with the belief that they will be covered per the terms of their insurance, and they are oftentimes not made aware of out-of-network services or providers until after they’ve received care. The frequency of surprise medical bills has led legislators to work to find solutions, including placing a cap on out-of-network charges and resolving out-off-network disputes between insurers and providers in arbitration.
EHCNote:
The surprising frequency of out-of-network claims has increasingly become an issue that legislators across the country are taking interest in. They are tackling issues both on a case-by-case basis and a larger scale. This issue can have a negative impact on hospital-based groups’ ability to negotiate with their networks and the hospitals they contract with putting the group at continued risk. Difficulty contracting with payers leads to increased difficulty achieving reimbursement and can result in lower overall compensation and/or an increased subsidy ask.
Dr. Howard Greenfield is a board-certified anesthesiologist with expertise in cardiac anesthesia, pain management, and healthcare consulting. A founding partner of Sheridan Healthcare, he led anesthesia operations at Memorial Regional Hospital and helped establish trauma and pediatric programs. He later served as VP of Business Development at Sheridan, expanding services nationally. In 2009, he co-founded Enhance Healthcare Consulting, where he’s spent over 13 years leading anesthesia and perioperative improvement initiatives across the U.S. with a data-driven, strategic approach.