Average in-network and OON payment amounts are converging in radiology
Average in-network and out-of-network payment amounts appear to be converging in radiology, according to a new analysis.
Research firm FAIR Health gave the example of CPT code 70450, used for a CT scan of the head or brain (without contrast). In 2019, prior to implementation of surprise-billing legislation, average in-network payment amounts allowed by insurers were higher than the OON average. However, the two values started inching closer together in 2023.
By Q3 of that year, the average in-network allowed amount was $65 versus $67 on the OON side, the nonprofit noted.
“Our report shows a trend toward convergence of average in-network and average out-of-network allowed amounts in common radiology procedure codes,” a FAIR Health spokesperson said by email. “This means less of a difference in allowed amounts whether the provider is in or out of network. There has also been a trend toward more in-network claims. Our data do not indicate the cause of these trends, though they have been occurring since the No Surprises Act became effective.”
Between 2019 and 2023, average billed amounts for CT of the head or brain, without contrast, increased by 17.4%, from $202 to $237. However, unlike other codes included in the analysis, average OON allowed amounts increased, too, by about 4.5%, FAIR Health noted. Meanwhile, average in-network allowed amounts dipped 14% during the same period.
This trend of convergence was seen across radiology and emergency medicine—two specialties highly impacted by surprise billing—codes sampled in the report. As another example, CPT 99284 (ED visit with moderate level of decision-making) saw the gap between average in-network and OON allowed amounts narrow during the study period.
From Q1 of 2019 to Q3 of 2023, radiology also had the highest in-network change (89.3% to 92%) compared to other “specialties of interest.” Emergency medicine had the lowest, with a range of 71.6% to 83.1%. FAIR Health also charted differences in these trends, based on geography. For example, in the South, there was a decrease in in-network care for 3 of the 4 specialties tracked—radiology, pathology and anesthesiology. And of all four specialties, radiology had the highest national percentage of in-network claim lines, which increased 4% since 2019.
The data seem to mirror a January report from the Neiman Health Policy Institute, which showed that radiologists were already predominantly in-network prior to the advent of the NSA. It also matches previous analyses demonstrating that the landmark legislation is working to help address OON surprise bills; however, it is also driving payments down and straining margins for radiology providers.
"The findings in this report have implications for stakeholders across the healthcare spectrum, including payers, providers, policy makers and patients,” FAIR Health President Robin Gelburd said in a statement. “We hope that these findings will also be starting points for further research on in-network and out-of-network utilization and pricing against the backdrop of federal and state surprise billing laws."
You can find the full report for free here.
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.