California Healthline Daily Edition

Summaries of health policy coverage from major news organizations

Insurers Point to High Out-of-Network Charges in New Report

In California and across the U.S., some physicians who provide out-of-network care charge significantly higher rates than what Medicare pays for certain treatments, according to a report from America's Health Insurance Plans, the Los Angeles Times reports.

For the report, AHIP surveyed health insurers in the 30 largest states about their highest bills for out-of-network services (Terhune, Los Angeles Times, 2/1).

Calif.-Related Findings

According to the report, a pathologist in California charged $8,100 for a tissue exam, which is 63 times higher than the $128 Medicare reimburses for the procedure.

Other out-of-network charges highlighted by California insurers included:

  • A $30,000 charge to remove a gallbladder using a laparoscope, for which Medicare reimburses $778;
  • A $23,360 charge for a knee arthroscopy, for which Medicare reimburses $640; and
  • A $19,272 charge to repair a bladder defect, for which Medicare reimburses $778 (AHIP survey, January 2013).

Implications for Policyholders

Some observers have criticized insurers for too often agreeing to pay excessive charges for out-of-network care and then passing along the increased costs to policyholders in the form of higher premiums (Los Angeles Times, 2/1).

According to the report, policyholders see measurable savings when they visit contracted health care providers because in-network physicians generally are prohibited from charging patients the difference between billed charges and a negotiated rate.

In addition, the report said that policyholders who receive treatment from in-network providers typically have lower cost-sharing obligations (AHIP survey, January 2013).

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