Institution for Social and Policy Studies

Advancing Research • Shaping Policy • Developing Leaders

Surprise! Out-of-Network Billing for Emergency Care in the United States

Author(s): 

Zack Cooper, Fiona Scott Morton, and Nathan Shekita

ISPS ID: 
ISPS17-22
Full citation: 
Cooper, Zack, Fiona Scott Morton, and Nathan Shekita (2017). Surprise! Out-of-Network Billing for Emergency Care in the United States, ISPS Working Paper, ISPS17-22.
Abstract: 
Using insurance claims data, we show that in 22% of emergency episodes, patients attended in-network hospitals, but were treated by out-of-network physicians. Out-of-network billing allows physicians to significantly increase their payment rates relative to what they would be paid for treating in-network patients. Because patients cannot avoid out-of-network physicians during an emergency, physicians have an incentive to remain out-of-network and receive higher payment rates. Hospitals incur costs when out-of-network billing occurs within their facilities. We illustrate in a model and confirm empirically via analysis of two leading physicianoutsourcing firms that physicians offer transfers to hospitals to offset the costs of out-of-network billing and allow the practice to continue. We find that a New York State law that introduced binding arbitration between physicians and insurers to settle surprise bills reduced out-ofnetwork billing rates.
Publication name: 
Publication type: 
Supplemental information: 

This paper is also available as a NBER working paper, link here.

Publication date: 
2017
Location: 
External ID: 
NBER Working Paper No. 23623
Discipline: 
Area of study: