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Analysis

Who's Most Guilty of Surprise Billing? Pathologists.

By Alexandra Wilson Pecci  
   May 29, 2020

New Health Care Cost Institute research shows that although more than half of providers in each specialty never billed out of network, some did so more than 90% of the time.

The prevalence of out-of-network billing isn't distributed equally among provider specialties or even among providers within those specialties, according to new research from the Health Care Cost Institute.

The researchers examined the distribution of out-of-network claims among individual clinicians in 2017 in six specialties: emergency medicine, pathology, radiology, anesthesiology, behavioral health, and cardiovascular services, using a sample of 13.8 million visits by more than 35,000 unique providers.

They found that more than half of providers in each specialty never billed out of network. Those who did, did so less than 10% of the time.

However, some providers—especially those in pathology—billed out of network more than 90% of the time.

The research also shows that:

  • The share of providers with at least one out-of-network claim associated with an in-network inpatient stay varied from a low of 18% for cardiology to 44% emergency medicine. For outpatient visits, it ranged from a low of 15% for behavioral health to a high of 49% for emergency medicine.
     
  • 36% of pathologists billing out of network for inpatient visits and 20% of pathologists billing out of network for outpatient visits did so more than 90% of the time. No other provider group billed out of network at this high a rate.  

This research comes as a new report from Politico says the White House will once again try to tackle the issue of surprise billing, possibly by including it in the next rescue package for COVID-19.

According to the Health Care Cost Institute authors, studies like theirs could help shape policies for doing so effectively.

"Understanding the variation in how frequently providers bill out-of-network across specialties can help stakeholders craft targeted policy solutions when addressing the adverse effects of out-of-network bills," they wrote. "This is important to ensure that people are not unfairly saddled with medical bills for unknowingly receiving services from an out-of-network provider."

Alexandra Wilson Pecci is an editor for HealthLeaders.


KEY TAKEAWAYS

36% of pathologists who billed out of network for inpatient visits did so more than 90% of the time.

The share of providers with at least one out-of-network claim associated with an in-network inpatient stay varied from a low of 18% for cardiology to 44% emergency medicine.

The research comes as the White House is reportedly once again looking to tackle the surprise billing issue.


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