National Assessment of Surprise Coverage Gaps Provided to Simulated Patients Seeking Emergency Care

Vivek Parwani,Craig Rothenberg,Jeremiah Kinsman,Arjun Venkatesh,Matthew Duhaime,Melissa Thomas,Andrew Ulrich

doi:10.1001/jamanetworkopen.2020.6868

Vivek Parwani, Craig Rothenberg + Show 5 more

Open Access

https://doi.org/10.1001/jamanetworkopen.2020.6868

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Abstract

This cross-sectional study evaluates surprise coverage gaps in health insurance by using secret shopper phone call methods to assess whether hospital billing staff in the US are able to answer a set of patient questions about insurance coverage.

Highlights

Surprise out-of-network bills, which essentially represent surprise coverage gaps, have recently garnered public outrage and the attention of Congress
Responses received by patients showed that separate professional billing for emergency department (ED) physicians varies by state, with North and South Dakota and several northwestern states having a comparatively higher prevalence of separate billing (Figure)
Among 2435 hospitals with billing staff responding that they do not employ their emergency physicians or giving an unclear response, 2092 (85.9%) were unable or unwilling to answer the question of who employed their ED physicians

Summary

Introduction

Surprise out-of-network bills, which essentially represent surprise coverage gaps, have recently garnered public outrage and the attention of Congress. These coverage gaps occur when patients seek hospital-based services and incur charges from multiple providers participating in different insurance networks or from out-of-network providers practicing at an in-network hospital. Emergency care has been a central focus of policy makers, as patients have no option to select a provider, and the magnitude of charges can be enormous.[1]. Increasing transparency, especially price transparency, has been heralded as a consumer-based solution to the high price of health care.[2] price transparency does not necessarily imply coverage transparency. We examined surprise coverage gaps from the patient perspective by conducting a national cross-sectional study of hospitals by using secret shopper phone call methods to assess whether patients could receive timely responses to 3 simple insurance coverage questions

Methods

Results

Conclusion