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Health Serv Res. 2013 Oct;48(5):1704-18. doi: 10.1111/1475-6773.12071. Epub 2013 Jun 6.

Patient experiences with involuntary out-of-network charges.

Author information

1
Department of Population Health, New York University School of Medicine, New York, NY.

Abstract

BACKGROUND:

Approximately 40 percent of individuals using out-of-network physicians experience involuntary out-of-network care, leading to unexpected and sometimes burdensome financial charges. Despite its prevalence, research on patient experiences with involuntary out-of-network care is limited. Greater understanding of patient experiences may inform policy solutions to address this issue.

OBJECTIVE:

To characterize the experiences of patients who encountered involuntary out-of-network physician charges.

METHODS:

Qualitative study using 26 in-depth telephone interviews with a semi-structured interview guide. Participants were a purposeful sample of privately insured adults from across the United States who experienced involuntary out-of-network care. They were diverse with regard to income level, education, and health status. Recurrent themes were generated using the constant comparison method of data analysis by a multidisciplinary team.

RESULTS:

Four themes characterize the perspective of individuals who experienced involuntary out-of-network physician charges: (1) responsibilities and mechanisms for determining network participation are not transparent; (2) physician procedures for billing and disclosure of physician out-of-network status are inconsistent; (3) serious illness requiring emergency care or hospitalization precludes ability to choose a physician or confirm network participation; and (4) resources for mediation of involuntary charges once they occur are not available.

CONCLUSIONS:

Our data reveal that patient education may not be sufficient to reduce the prevalence and financial burden of involuntary out-of-network care. Participants described experiencing involuntary out-of-network health care charges due to system-level failures. As policy makers seek solutions, our findings suggest several potential areas of further consideration such as standardization of processes to disclose that a physician is out-of-network, holding patients harmless not only for out-of-network emergency room care but also for non-elective hospitalization, and designation of a mediator for involuntary charges.

KEYWORDS:

Qualitative methods; health policy; managed care; out-of-network care

PMID:
23742754
PMCID:
PMC3796109
DOI:
10.1111/1475-6773.12071
[Indexed for MEDLINE]
Free PMC Article

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