About one of every six emergency room visits and inpatient hospital stays for patients with large employer plans resulted in at least one out-of-network medical bill in 2017, according to a study from the Kaiser Family Foundation.
To determine the incidence of surprise medical bills, researchers examined large employer claims data from IBM’s MarketScan Research Database, representing claims and encounters for nearly 19 million people. Researchers said they could use the database to see the frequency emergency room visits by members and out-of-network charges.
They were also able to see when a member was admitted to an in-network hospital or other facility and received out-of-network charges for services. They note that the study was limited in that it did not include denied claims.
Overall, the study estimated 18 percent of emergency room visits in 2017 by people with large employer plans resulted in one or more out-of-network charge (from the facility, the provider, or both).
Out-of-network billing in emergency settings for people with large employer plans were most common in Texas, New Mexico, New York, California and Kansas. This was less common in Minnesota, South Dakota, Nebraska, Alabama and Mississippi, according to the study.
Researchers also found that on average, 16 percent of in-network inpatient admissions in 2017 among people with large employer plans resulted in at least one out-of-network charge.
"In many of these cases, the patient not only is at risk of being balanced-billed by the provider, but also likely faces higher out-of-pocket costs under her insurance plan for the out-of-network claims," they wrote.
The study found that the share of in-network inpatient stays with at least one out-of-network charge varied by state. The share was 2 percent in South Dakota, Nebraska and Minnesota, but about a quarter or more in New York (33 percent), New Jersey (29 percent), Texas (27 percent) and Florida (24 percent).
Access the study here.
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