Healthcare Revenue Cycle Management, ICD-10, Claims Reimbursement, Medicare, Medicaid

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Unexpected Patient Financial Responsibility in 20% of ED Cases

About 1 in 5 inpatient admissions from an emergency department visit resulted in unforeseen patient financial responsibility from surprise medical bills, study showed.

By Jacqueline LaPointe

- Approximately 20 percent of hospital admissions stemming from an emergency department visit in 2014 led to unexpected patient financial responsibility in the form of surprise medical bills, a recent Health Affairs study reported.

Emergency department visits are likely to end with unanticipated patient financial responsibility in the form of surprise medical bills, study finds

Using national claims data from 2007 to 2014, researchers also found that patients were more likely to be hit with unanticipated patient financial responsibility for outpatient emergency department visits and elective inpatient admissions, too.

In 2014, about 14 percent of outpatient visits to the emergency department and 9 percent of elective inpatient admissions resulted in surprise medical bills, or unexpected bills a patient gets from an out-of-network provider or from an out-of-network provider the patient didn’t choose.

However, the study showed that unanticipated patient financial responsibility rates have decreased since 2007 from 28 percent of hospital inpatient admissions from the emergency department, 18 percent of outpatient visits to the emergency room department, and 14 percent of elective inpatient admissions.

Researchers theorized that lower surprise medical bill rates may be linked to an increase in hospital-employed physicians. A September Health Affairs study reported that the number of providers in group practices of nine or fewer physicians decreased from 40.1 percent in 2013 to 35.3 percent in 2015.

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However, the number of providers in group practices of 100 or more physicians increased from 29.6 percent to 35.1 percent in the same period.

With more provider consolidation, researchers in the most recent study stated that surprise medical bills are less likely because hospitals and employed providers jointly negotiate with health plans.

Despite recent reductions in unexpected patient financial responsibility, researchers reported that the chances of receiving a surprise medical bill increased with a patient’s age.

For example, the lowest potential of surprise medical bills for inpatient admissions from the emergency department was at 14.5 percent for individuals up to 17 years old. Similarly, potential surprise medical bill rates for elective inpatient admissions and outpatient emergency room visits were the lowest at 6.3 percent and 12.3 percent, respectively.

In contrast, individuals aged 55 to 64 years had the highest potential for surprise medical bills for a variety of services. The rates were 21.6 percent for inpatient admissions from the emergency department, 12.6 percent for elective inpatient admissions, and 15.9 percent for outpatient emergency department visits.

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Higher medical severity and complexity levels also led to more unexpected patient financial responsibility. For example, the multiple significant trauma diagnosis had the greatest potential for surprise medical bills with 25 percent for inpatient admissions from the emergency department and 19.2 percent for elective inpatient admissions.

Emergency department inpatient admissions were also more likely than outpatient emergency department visits to generate a surprise medical bill, indicating that the potential to receive a surprise medical bill increased with the severity and complexity of a patient treatment episode.

Researchers added that emergency department inpatient admissions that were likely to produce unanticipated patient financial responsibility had longer length-of-stays and more procedures and services compared to inpatient admissions that did not result in a surprise medical bill.

“This is troubling because one objective of insurance is to offer proportionately more protection in situations that are extreme and costly,” wrote study authors. “However, our results suggest that prolonged exposure to relatively high numbers of physicians and services increases the likelihood that a patient will receive a surprise medical bill.”

While researchers linked patient age and medical complexity to surprise medical bills, they also found that non-hospital-based physicians were the most likely to cause unexpected patient financial responsibility.

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However, surprise medical bills came from a wide range of provider types. For instance, 17 percent of elective inpatient admissions that were likely to result in surprise medical bills involved an out-of-network anesthesiologist, but 12 percent involved an out-of-network pathologist.

Additionally, researchers revealed that surprise medical bills varied across states. But they were more prevalent among hospital inpatient admissions from an emergency department visit in Florida (37 percent), New York (35 percent), and Texas (34 percent).

Some states, like New York, are fighting against unexpected medical bills. In 2015, New York enacted a law that limited the number of surprise medical bills patients could receive from an out-of-network clinician when receiving treatment at an in-network hospital or medical facility.

New York lawmakers designed the law to ensure all patients who receive emergency care regardless of health plan networks are only held accountable for costs related to in-network health plan cost-sharing.

As of April, 48 other states have enacted similar laws, but New York’s is the most comprehensive, reported the National Academy for State Health Policy. For example, 27 states currently apply protection against out-of-network providers in PPO plans and 13 states have protections for HMO plans.

Although, the Health Affairs study showed that states with the highest potential for surprise medical bills, such as Florida, New York, and Texas, recently passed legal patient protections for unexpected patient financial responsibility.

Dig Deeper:

Key Ways to Boost Collection of Patient Financial Responsibility

Ensuring Care Access with High Patient Financial Responsibility

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