Policies needed to address the rising problem of surprise out-of-network doctor bills
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With the birth of my second son, I (Dr. Kyanko) found myself facing a $600 surprise out-of-network bill from a pediatrician called into the delivery room when there was some concern over complications (he turned out just fine). This situation is not uncommon for Americans. Surprise or unexpected out-of-network bills can happen in an emergency when a patient is ill and unable to seek out an in-network emergency room or is taken to an out-of-network emergency room by ambulance. Patients can also receive surprise out-of-network bills from an out-of-network doctor at an in-network hospital (as was my case) or if an insurer’s provider network directory is not accurate. In a 2011 national survey of privately insured adults, we found that unexpected use of an out-of-network doctor was common - about 40% of individuals using an out-of-network doctor did not intend to do so.

Given the work I had done studying out-of-network bills, I was excited to put my knowledge about this issue into action and call my insurance company to dispute the bill.  But nine phone calls and two and half hours later spent arguing with the insurance company and the doctor’s office, the novelty wore off and left me wondering how patients with much less expertise than my own, not to mention chronic medical problems with many more bills, managed.

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Often enough they do not. In most states, the burden is placed on consumers to avoid and dispute out-of-network charges. But many patients don’t negotiate, or are not successfully able to dispute these bills. We found in a new study published in the American Journal of Managed Care that one in five patients using out-of-network care attempt to negotiate with insurers or doctors, with only half receiving a reduction in price. Even at in-network hospitals only about 37 percent of negotiated bills resulted in lower costs to the patient. We also found that women and people in poor health were less likely to be successful in negotiating out-of-network bills.

My bill was $600, but there is no limit to how much out-of-network doctors can charge and these bills can be extraordinarily high - even tens of thousands of dollars. Research has found that out-of-network bills are a common source of medical debt among the privately insured. This issue has become more important with the increase in “narrow network” plans that offer low premiums but a limited choice of doctors and hospitals. Nationally, in 2014, 41 percent of Exchange plans were considered small or extra small, but in some states it was much higher – 75 percent of plans in California had small or extra small networks. Many consumers don’t know where to go for help - a 2015 Consumer Reports survey found that most privately insured don’t know the agency in their state that manages health insurance complaints.

We are starting to see help for patients who have so far bared the brunt of a process that can be time-consuming, frustrating, and often unsuccessful. In 2015, New York State passed a comprehensive law to protect patients from surprise out-of-network bills, which included an independent mediation process that excludes patients and forces doctors and insurers to settle on payment themselves. While this policy is relatively new and we don’t have data about its effectiveness, many consumer advocates see this as a good solution and other states such as are California and Florida have implemented similar policies.

Ideally, we would keep these bills from happening in the first place. Plans should keep their provider directories updated and accurate. Hospitals and doctors could ensure that all of the doctors a patient might see in a hospital will accept their insurance. Insurers can provide more protections for patients with surprise bills.

In the end, I was able to negotiate away my surprise out-of-network bill after the insurer and doctor agreed I was not liable. But as our study shows, there is no guarantee this can happen, especially for people who may not be as savvy. Having a policy that doesn’t provide protection when you need it most is really no insurance at all.

Kelly A. Kyanko, MD, MHS, is an assistant professor at New York University School of Medicine and Susan H. Busch, PhD, is a Professor at Yale School of Public Health


The views expressed by authors are their own and not the views of The Hill.