Is out-of-network billing – when a patient receives care outside their insurance network – still a problem in radiology? A new study in JACR shows that out-of-network commercial claims have dropped dramatically since 2007.
Out-of-network healthcare has been the focus of a number of legislative efforts in recent years as lawmakers try to protect patients from the financial sting of getting a big bill for services rendered outside their provider’s network.
- Probably the centerpiece of this effort is the federal No Surprises Act, which went into effect in January 2022; not only did it cap the amount that patients can be billed for out-of-network services, but it created an independent dispute resolution mechanism for adjudicating disagreement between providers and payors over how much they should be paid.
The IDR mechanism has been the focus of legal wrangling in recent months, but the new study in JACR indicates that it might not be getting much use after all, at least in radiology.
Researchers from the ACR’s Harvey L. Neiman Health Policy Institute analyzed 80M commercial claims for radiology services from 2007 to 2021, finding…
- Out-of-network radiology claims fell dramatically (to 1.1% vs. 13%)
- Out-of-network claims fell for inpatient stays (to 1.4% vs. 10%)
- Claims also fell for emergency visits (to 0.4% vs. 3.9%)
- By modality, most claims were for X-ray (57%), followed by ultrasound and CT (15% each)
- By 2021, radiologists practiced almost exclusively in-network
What’s the reason for the dramatic decline? The study authors credit good-faith negotiations between radiology practices and commercial payors, as well as the impact of state surprise billing laws (the study period occurred before the federal No Surprises Act went into effect).
- Other possible factors include consolidation among practices, hospitals, and payors; expansion of academic centers into communities; and the COVID-19 pandemic.
The JACR study is welcome news for both patients and radiology practices. Patients are less likely to be hit with surprise medical charges, while practices are less likely to have to fight through the IDR process to resolve claims. In the end, everybody wins – even insurance companies.