Out-Of-Network Billing And Negotiated Payments For Hospital-Based Physicians
Out-Of-Network Billing And Negotiated Payments For Hospital-Based Physicians
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DOI：
10.1377/hlthaff.2019.00507
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发表时间：
2020-01-01
期刊：
影响因子：
9.7
通讯作者：
Morton, Fiona Scott
中科院分区：
文献类型：
--
作者：
Cooper, Zack;Hao Nguyen;Morton, Fiona Scott
当患者不选择也无法避免的医生可以在网络外为网络内医院提供的护理收费时，这使患者面临财务风险，并削弱了医疗保健市场的运作。使用一家大型商业保险公司2015年的数据，我们发现，在网络内医院中，11.8%的麻醉护理，12.3%的病理学家护理，5.6%的放射科医生索赔，以及11.3%的涉及助理外科医生的病例在网络外计费。网络外计费的能力允许这些专家协商人为的高网络内费率。在集中的医院和保险市场以及营利性医院，网络外计费更为普遍。我们的估计表明，如果这些专家不能从网络中收费，私人保险患者的医生支付将减少13.4%，雇主赞助保险的医疗保健支出将减少3.4%（每年约400亿美元）。
When physicians whom patients do not choose and cannot avoid can bill out of network for care delivered within in-network hospitals, it exposes patients to financial risk and undercuts the functioning of health care markets. Using data for 2015 from a large commercial insurer, we found that at in-network hospitals, 11.8 percent of anesthesiology care, 12.3 percent of care involving a pathologist, 5.6 percent of claims for radiologists, and 11.3 percent of cases involving an assistant surgeon were billed out of network. The ability to bill out of network allows these specialists to negotiate artificially high in-network rates. Out-of-network billing is more prevalent at hospitals in concentrated hospital and insurance markets and at for-profit hospitals. Our estimates show that if these specialists were not able to bill out of network, it would lower physician payments for privately insured patients by 13.4 percent and reduce health care spending for people with employer-sponsored insurance by 3.4 percent (approximately $40 billion annually).