The unintended financial impact on patients of hospital based physicians opting out of commercial insurance networks

Luis J Garcia Morales, The University of Texas School of Public Health


Objective: This study assesses the percentage of Out-of-Network volume at in-network facility and its financial impact for services provided by Emergency Department (ED) physicians and anesthesiologists. Specifically, the research aims to better understand the magnitude of the problem in terms of both volume of out-of-network claims and average financial burden. Methods: The research analyzed BCBS claims data 2009-2013. It focused on professional claims for out-of-network care at in-network facility limited to ED physicians for the top four discharge diagnoses for all payer sources in all age groups. For anesthesiology, the research analyzed cesarean section, a regularly planned procedure and, fracture, commonly unexpected. These are two of the most frequent inpatient surgeries requiring anesthesia for patients age 15 to 44 from CDC/NCHS National Hospital Discharge Survey 2010. Key findings: For ED physicians, 6,556 in-network claims were analyzed. The percentage of out-of-network care at in-network facility has been 5.77% on average for the 5-years. The percentage for professional claims involving medical history, examination and complex medical decision making reached its peak in 2012 and declined in 2013. Other claims with medical history, examination and moderate medical decision making reached 0% out-of-network claims by 2013. The financial patient responsibility between out-of-network care and in-network care was over 130% of the in-network out-of-pocket cost for the complex medical decision making claim. The financial patient responsibility for the moderate medical decision making was 62% more for out-of-network care. For anesthesiology, the study included 57,268 claims. The percentage of out-of-network care for both procedures had an average of 1.72% for all 5-years. Both had the highest percentage for out-of-network volume in 2012 with 3% followed. The financial percentage was 412% higher for out-of-network care out-of-pocket cost. For cesarean section, out-of-network out-of-pocket was 288% higher. Conclusion: The literature review pointed to a large percentage of out-of-network visits with even bigger incidence in-network facilities. However, throughout our results we found ED highest percentage to be just above 15 percent and it was for the interpretation of ECG. The medical care requiring history, examination and medical decision making did not surpass 9.5 percent and in one of the CPT codes reached 0 percent by 2013 giving no out-of-network visits in the year. For anesthesia, the highest percentage reached 3.28 percent in the fracture group and both ended below 1 percent for out-of-network care. The financial impact was not as high as originally expected. It might seem tolerable for one visit but repetitive visits during a year, from one or more family members could start creating a bigger impact on the family finance.

Subject Area

Health care management

Recommended Citation

Garcia Morales, Luis J, "The unintended financial impact on patients of hospital based physicians opting out of commercial insurance networks" (2015). Texas Medical Center Dissertations (via ProQuest). AAI1603947.