Surprise! Out-of-Network Billing for Emergency Care in the United States

Out-of-network billing allows physicians to significantly increase their payment rates relative to what they would be paid for treating in-network patients…………...

Surprise! Out-of-Network Billing for Emergency Care in the United States

Zack CooperFiona Scott MortonNathan Shekita

NBER Working Paper No. 23623
Issued in July 2017
NBER Program(s):   HC

Using insurance claims data, we show that in 22% of emergency episodes, patients attended in-network hospitals, but were treated by out-of-network physicians. Out-of-network billing allows physicians to significantly increase their payment rates relative to what they would be paid for treating in-network patients. Because patients cannot avoid out-of-network physicians during an emergency, physicians have an incentive to remain out-of-network and receive higher payment rates. Hospitals incur costs when out-of-network billing occurs within their facilities. We illustrate in a model and confirm empirically via analysis of two leading physician-outsourcing firms that physicians offer transfers to hospitals to offset the costs of out-of-network billing and allow the practice to continue. We find that a New York State law that introduced binding arbitration between physicians and insurers to settle surprise bills reduced out-of-network billing rates.

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