Radiologists were already nearly 99% in-network before the No Surprises Act took effect in 2022, with health insurers’ misuse of the law potentially eroding that number, experts detailed Friday in JACR [1].
The specialty has improved upon its out-of-network rate since 2007, falling from nearly 13% down to 1% as of 2021. The shift is likely attributable (at least in part) to effective negotiations between radiologists and commercial payers, provider consolidation, and passage of state-level surprising billing legislation, Neiman Health Policy Institute researchers noted.
However, the No Surprises Act’s implementation threatens to derail such progress. Commercial insurers are using the legislation as a cudgel, forcing in-network physicians to accept lower payment or risk being carved out of crucial commercial contracts, industry watchers note.
“To the degree that the No Surprises Act rulemaking decreases the incentive for insurers to maintain their provider networks—because patients are only required to pay the in-network rate, which, in turn, increases the bargaining power of insurers—we may see the radiology OON share increase in 2022 and beyond,” lead author Jay Parikh, MD, a professor at the University of Texas MD Anderson Cancer Center, said in a Jan. 19 announcement. “If so, the No Surprises Act rulemaking may be counterproductive to the law’s intent.”
For the study, Parikh and colleagues analyzed information from Optum’s commercial claims database spanning 15 years. They estimated that, from 2007 to 2021, about 5 million (or 6%) of radiologists’ imaging claims were considered out of network. This included about 5% for inpatient stays and 2% on the same day as an emergency department visit that did not lead to a hospital admission. Each year, the overall out-of-network rate for rads declined at a steady clip of 0.74 percentage points (0.54 for inpatient stays and 0.26 for ED visits). Over 15 years, the inpatient OON rate fell from 10% to 1% and 4% to 0.4% in the ED.
Study authors highlighted a slight uptick in the OON rate between 2014 and 2018, which may stem from the “market forces of consolidation and lack of preexisting insurance contracts by newly formed consolidated practices.”
The overall decline also occurred broadly across imaging modalities, Parikh et al. reported. There was “relative homogeneity” of the downward trend of OON billing, with no significant difference for costlier advanced imaging modalities such as MRI and CT.
“These overall and modality specific trends may suggest effective efforts of radiologists to negotiate rates to be in network rather than engage in OON billing and that insurers have sought to expand their radiology networks,” the study reported.
Read much more at the link below. The analysis was supported by the Neiman Health Policy Institute, which released another study about the No Surprises Act on Jan. 17.
Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic.