FIGHTING SURPRISE OUT-OF-NETWORK DOCTOR BILLS
The 32BJ Health Fund is taking on surprise bills from out-of-network (OON) providers. Health Fund Director Sara Rothstein testified at a December 12th New York City Council hearing about the problem of surprise bills from OON providers and called on the City Council to require hospitals with physical locations in New York City to disclose the insurance networks accepted by each hospital, the total number of doctors with credentials at each hospital and the total number of doctors who are in each insurance and/or benefit network accepted by each hospital. The issue and Rothstein’s comments got extensive coverage in Bloomberg and other outlets.
When plan participants receive a surprise bill from an OON provider for services performed at an in-network hospital, the Health Fund ensures that participants don’t pay more for needed care than they would have paid if services were performed by an in-network provider. When surprise bills cost significantly more than what an in-network provider would have been paid for the same care, the Health Fund must pay more to the OON provider than it would have paid to an in-network provider. These expensive bills jeopardize the Health Fund’s ability to keep costs low for participants and for contributing employers.
PREVALENCE OF OON PROVIDERS BY HEALTH SYSTEM
The Health Fund analyzed claims from OON providers who provided care to a Health Fund plan participant in an inpatient or outpatient hospital setting. This analysis identified the following:
- The Health Fund paid $4,237,680 to OON providers who provided care at a Northwell hospital. This is more than the total amount that the Health Fund paid to OON providers at any other health system in downstate New York.
- Number of Claims from OON Providers – The Health Fund had 5,751 claims from OON providers at Northwell hospitals, which were more OON provider claims than at any other health system in downstate New York.
- Number of OON Providers – The Health Fund paid 947 OON providers at Northwell hospitals, which was more OON providers than at any other health system in downstate New York.
- The Health Fund analyzed claims from OON providers providing care at Northwell hospitals to determine if the OON claims were concentrated in certain specialties. The Health Fund found that 39% of the claims and 42% of dollars spent were from Internal Medicine and Cardiology providers combined at Northwell hospitals.
Surprise bills aren’t only a matter of concern to the Health Fund. Patients and other payers alike should be concerned about the prevalence of OON providers providing care to patients at Northwell hospitals. When a health system is in network, patients expect that the providers who provide care there are also in network. This is especially true when patients are already admitted to an in network hospital and don’t have a choice of provider.
The 32BJ Health Fund introduced a new and innovative network design in April 2019. For the first time in its history, it differentiated between health systems in the New York City metro area. While most health systems would be preferred and keep the same low copays, others that charged significantly more for care would become non-preferred and have significantly higher copays for planned care. While most plan participants were already using preferred hospitals, the goal of the new design is to increase the number of participants using preferred hospitals when they need hospital-based care.
