The risk of unintentional out-of-network encounters with hospital-based physicians at in-network hospitals

Brown, Lawrence H., Weston, Robert A., and Gough, John E. (2017) The risk of unintentional out-of-network encounters with hospital-based physicians at in-network hospitals. American Journal of Emergency Medicine, 35 (9). pp. 1228-1233.

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Abstract

Objective: When hospital-based specialists including emergency physicians, anesthesiologists, pathologists and radiologists are not included in the same insurance networks as their parent hospitals, it creates confusion and leads to unexpected costs for patients. This study explored the frequency with which hospital-based physicians at academic medical centers are not included in the network directories for the same insurance networks as their parent teaching hospitals.

Methods: We studied teaching hospitals with residency programs in all four hospital-based specialties. Using insurance plan provider directories, we determined whether each teaching hospital was in-network for randomly selected locally available insurance plans offered through the federal and state marketplace exchanges. For each established hospital-network relationship, we then determined whether hospital-based specialists were included in the provider network directory by searching for the name of each specialty's residency program director and the name of the physician practice group.

Results: We identified 79 teaching hospitals participating in 144 locally available insurance plan networks. Hospital-based specialist inclusion in these hospital-network relationships was: emergency physicians: 50.0% (CI: 40%-59%); anesthesiologists: 50.0% (CI: 42%-58%); pathologists: 45.4% (CI: 37%-54%); and radiologists: 55.1% (46%-64%). Inclusion of all four hospital-based specialties occurred in only 45.0% (CI: 36%-54%) of the hospital-network relationships.

Conclusion: For insurance plans offered through the federal and state marketplace exchanges, hospital-based specialists frequently are not included in the directories for the insurance networks in which their parent teaching hospitals participate. Further research is needed to explore this issue at non-academic hospitals and for off-exchange insurance products, and to determine effective policy solutions. (C) 2017 Elsevier Inc. All rights reserved.

Item ID: 50434
Item Type: Article (Research - C1)
ISSN: 1532-8171
Keywords: Patient Protection and Affordable Care Act, health insurance, insurance coverage, managed care programs
Date Deposited: 20 Sep 2017 08:56
FoR Codes: 11 MEDICAL AND HEALTH SCIENCES > 1117 Public Health and Health Services > 111799 Public Health and Health Services not elsewhere classified @ 20%
16 STUDIES IN HUMAN SOCIETY > 1605 Policy and Administration > 160508 Health Policy @ 80%
SEO Codes: 92 HEALTH > 9202 Health and Support Services > 920299 Health and Support Services not elsewhere classified @ 100%
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