Other research says the policy is working and strengthening provider networks The physicians interviewed in the case study said that their decreased leverage is exacerbating provider consolidation.Ĥ.
#MEDICAL BILLINGS PROFESSIONAL#
A case study appearing in the August issue of The American Journal of Managed Care ® found that while the law, AB-72, is effectively protecting patients from surprise medical bills, stakeholders report that the payment standard set at payer-specific local average commercial negotiated rates has changed the negotiation dynamics between hospital-based physicians and payers.Īccording to the 28 interviews with policy experts, representatives of advocacy organizations and state-level professional associations, and current executives of physician practice groups, the leverage has shifted in favor of payers, who have an incentive to lower or cancel contracts with rates higher than their average as a way to suppress out-of-network prices. In 2017, California implemented a policy to address surprise medical billing for out-of-network nonemergency physician services at in-network hospitals, which includes a novel out-of-network payment standard.
Some research says implementing payment standards to address the issue could have negative consequences Meanwhile, the percentage of inpatient admissions that had an out-of-network bill increased from 26.3% to 42.0% and the average potential cost to the patient increased from $804 to $2040.ģ. During the same period, the average potential cost for patients increased from $220 to $628. Looking at health insurance claims for people with private insurance from a large commercial insurer between 20, the researchers saw that the percentage of emergency department visits resulting in an out-of-network bill increased from 32.3% to 42.8%. The prevalence of surprise medical bills is not just high it continues to increase, according to a study published in JAMA Internal Medicine, which found that out-of-network billing continues to be more common for patients with private insurance even when visiting an in-network hospital. The prevalence of surprise medical bills continues to increase
Polls from KFF have found that two-thirds of Americans are “very worried” (38%) or “somewhat worried” (29%) about being able to afford their own or a family member’s surprise medical bill.Ģ. Meanwhile, in states like Texas, New Mexico, California and New York, at least 30% of visits resulted in an out-of-network charge. For example, in states like Minnesota, South Dakota, Nebraska, Alabama, and Mississippi, 5% of emergency visits ended with an out-of-network bill. However, the prevalence varies widely between states. The analysis of large employer plans revealed that 18% of all emergency visits and 16% of in-network hospital stays resulted in at least 1 out-of-network bill. Surprise medical bills impact a significant amount of emergency room visitsĪn analysis from Kaiser Family Foundation (KFF) found that patients came home with at least 1 out-of-network bill in approximately 1 out of every 6 emergency room visits in 2017.
The impact of surprise medical billing, which occurs when a patient receives care from a doctor or hospital outside of their insurer's network and the doctor or hospital subsequently bills the patient for the amount their insurance didn't cover, has also garnered attention from healthcare stakeholders and the federal government. Surprise medical billing has made headlines over the last year, detailing stories of patients left with thousands of dollars of medical costs after receiving medical care they thought was covered by their insurance.