Out-of-network billing by hospital-based specialists boosts spending by $40 billion

December 16, 2019 / SHELBY LIVINGSTON 

Patients who seek care at in-network hospitals have a significant risk of being treated by and receiving a surprise bill from out-of-network anesthesiologists, pathologists, radiologists or assistant surgeons, a new study by Yale University researchers found.

The ability of these four specialties to send patients out-of-network bills allowed them to negotiate high in-network payments from insurers, which leads to higher insurance premiums for individuals, according to the study published Monday in Health Affairs.

Were the specialists unable to bill out of network, employer-sponsored healthcare spending would be 3.4%, or about $40 billion, lower per year, researchers concluded.

“When physicians whom patients cannot avoid can work out of network from in-network hospitals, it exposes patients to significant financial risk and raises physicians’ in-network payments,” the researchers wrote in the study.

Because hospitals and physicians separately negotiate payments and network participation with health insurers, it’s possible for a patient to see an out-of-network physician at an in-network hospital. Those physicians may send patients a “surprise” medical bill for services that the insurer would not cover.


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Chris J. Stewart

Chris currently serves as Chief Executive Officer of Surgio Health as well as COO at Ortho Spine Partners. Chris has close to 20 years of healthcare management experience with an infinity to improve healthcare delivery through the development and implementation of innovative solutions that solve real problems that result in improved efficiencies, reduction of unnecessary financial & clinical variation, and help drive better patient outcomes. Previously, Chris was assistant vice president and business unit leader for HPG/HCA. He has presented at numerous healthcare forums on topics that include disruptive innovation, physician engagement, shifting reimbursement models, cost per clinical episode and the future of supply chain delivery.

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