To increase revenue from out-of-network claims, there are several things providers can do, including: Identify and track all out-of-network claims. Require all networks to be identified in the contract. Eliminate contracts that include silent PPOs. Limit authorization to negotiate discounts. Establish out-of-network metrics.
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Out-Of-Network Utilization and Plan Selection Among Medicare Advantage Cost Plan Enrollees.
Health Serv Res
January 2025
Schaeffer Center for Health Policy & Economics, Price School of Public Policy, University of Southern California, Los Angeles, California, USA.
Objective: To understand how Medicare Advantage (MA) networks impact utilization patterns and plan choices, using the 2019 discontinuation of MA 1876 Cost plans as a natural experiment.
Study Setting And Design: We study 1876 Cost plans, MA plans for which out-of-network care is covered through traditional Medicare (TM) and many of which CMS discontinued in 2019. We characterize the proportion of Cost plan enrollees who utilized out-of-network care in 2018 from different types of medical specialties.
The impact of surprise billing laws on hospital-based physician prices and network participation.
Health Econ Policy Law
December 2024
College of Public Health, Ohio State University, Columbus, OH, USA.
Prior to the No Surprises Act (NSA), numerous states passed laws protecting patients from surprise medical bills from out-of-network (OON) hospital-based physicians supporting elective treatment in in-network hospitals. Even in non-emergency situations, patients have little ability to choose physicians such as anaesthesiologists, pathologists or radiologists. Using a comprehensive, multi-payer claims database, we estimated the effect of these laws on hospital-based physician reimbursement, charges, network participation and potential surprise billing episodes.
View Article and Find Full Text PDFThe impacts of New York's balance billing regulation on ground ambulance pricing.
Health Serv Res
October 2024
Division of Health Services Management and Policy, College of Public Health, The Ohio State University, Columbus, Ohio, USA.
Objective: To examine the effects of New York's surprise billing regulations on price changes by emergency ground ambulance service providers.
Study Design: We exploited a natural experiment using a difference-in-differences design with randomization inference (RI) to examine the effects of New York state regulations on the prices of emergency ground ambulances, analyzing 2012-2019 commercial claims data. In March 2015, New York implemented a law protecting patients from surprise out-of-network (OON) balance bills, including ground ambulance services.
Neurointerventional payment for out-of-network mechanical thrombectomy in the era of the No Surprises Act.
J Neurointerv Surg
October 2024
Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA.
Article Synopsis
- The No Surprises Act (NSA), enacted by Congress in 2021, allows out-of-network providers to appeal payment disputes through an arbitration process called Independent Dispute Resolution (IDR), specifically evaluated for mechanical thrombectomy (MT).
- A simulation study found that neurointerventionalists generally need to submit multiple claims to make the IDR process financially viable; for professional claims, at least four are needed, while global claims require at least two.
- The results indicate that large MT centers rarely benefit from IDR for professional-only claims (0% viability), and only 13.2% of global claims are financially viable through IDR; smaller stroke centers show even less viability, raising concerns about inadequate reimbursement under NSA.
Ambulatory Surgery Centers Reduce Patient Out-of-Pocket Expenditures for Isolated Arthroscopic Rotator Cuff Repair, but Patient Out-of-Pocket Expenditures Are Increasing at a Faster Rate Than Total Healthcare Utilization Reimbursement From Payers.
Arthroscopy
June 2024
Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A.. Electronic address:
Purpose: To categorize and trend annual out-of-pocket expenditures for arthroscopic rotator cuff repair (RCR) patients relative to total healthcare utilization (THU) reimbursement and compare drivers of patient out-of-pocket expenditures (POPE) in a granular fashion via analyses by insurance type and surgical setting.
Methods: Patients who underwent outpatient arthroscopic RCR in the United States from 2013 to 2018 were identified from the IBM MarketScan Database. Primary outcome variables were total POPE and THU reimbursement, which were calculated for all claims in the 9-month perioperative period.
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