Surprise medical billing is one of the most pressing health care affordability concerns faced by American patients and families today. Surprise bills are unanticipated charges billed directly to patients when they were unknowingly provided care from an out-of-network (OON) provider.

  • At least one in five Americans will receive a surprise medical bill from an emergency physician they didn’t — or couldn’t — know was OON1.
  • Inflated charges by OON emergency physicians at in-network emergency departments totaled $6 billion in 20182.
  • OON anesthesiologists and radiologists charge nearly six and five times the Medicare reimbursement rate, respectively3.

Why it matters: Surprise bills are not the fault of patients. Patients go to receive care at an in-network hospital and presume their provider is in-network. The patient could be seen by one or multiple OON providers — who are not bound by contractual, in-network rate agreements with an insurance provider — resulting in a surprise bill for the entire remaining balance, often thousands of dollars.

How UnitedHealth Group Reduces Surprise Billing

Our health benefits platform UnitedHealthcare is working to empower patients with information, price transparency and a wide choice of the best providers. Read more about Value-Based Care.

More Ways to Reduce the Burden of Surprise Billing

More can be done to address surprise billing, especially when the patient is not able to choose their provider. Additional solutions include:

  • Establishing a market-based benchmark rate tied to the median locally negotiated rate.
  • Capping consumer out-of-pocket costs.
  • Requiring hospitals to notify patients when a provider is OON.
  • Disallowing OON facilities from charging additional facility fees to insurers.
  • Providing surprise billing protections for enrollees in fully insured and self-insured products.

A UnitedHealth Group analysis found that OON emergency department physicians charge on average 637% of what Medicare pays for the same services, and 2.4 times more than in-network commercial rates. Setting benchmark rates that are below average in-network rates would encourage providers to remain in-network or to join networks, and would eliminate surprise bills for consumers.

These proposed policy solutions would protect consumers from high out-of-pocket costs when they see OON providers at in-network facilities. These providers could remain OON and consumers would still be free to see them – only the patients would be held harmless financially.

 

 

References

1. Cooper, Z., & Morton, F. S. (2016). Out-of-Network Emergency-Physician Bills — An Unwelcome Surprise. New England Journal of Medicine, 375(20), 1915-1918
http://faculty.som.yale.edu/fionascottmorton/documents/NEJM_ED.pdf

2. Centers for Disease Control (CDC), “National Hospital Ambulatory Medical Care Survey: 2015 Emergency Department Summary Tables.”
https://www.cdc.gov/nchs/data/nhamcs/web_tables/2015_ed_web_tables.pdf

3. Ge Bai, PhD, CPA; Gerard F. Anderson, PhD (2017) “Variation in the Ratio of Physician Charges to Medicare Payments by Specialty and Region.” 
https://jamanetwork.com/journals/jama/fullarticle/2598253