America’s Health Insurance Plans (AHIP) has commissioned a study to show how medical billing looks from member health insurers’ perspective.
AHIP, a trade group for health insurers, hired a research firm, Dyckman & Associates, to help it analyze how physicians bill patients, and insurers, for services when no provider network contracts are in effect.
Dyckman asked member insurers to provide the three highest billed charges in 2011 and the corresponding ZIP codes from out-of-network providers in the 30 most populous states for each of 24 medical procedures.
Dyckman went through the data to exclude sky-high billed amounts that appeared to be the result of billing or claim reporting errors, AHIP said in a summary of Dyckman’s work.
Even after Dyckman analysts cleaned the claims data, they found one example of a bill for “subsequent hospital care” that was for $9,471, or about 95 times the reimbursement amount that the Medicare program would allow for that same procedure code, AHIP said.
In another case, the Dyckman analysts found that a surgeon billed a plan about $150,500 for repairing a hernia with a torso muscle skin grant. Medicare would pay only $1,766.57 for a graft of muscle skin from the trunk, AHIP said.
The states included in which the highest out-of-network billed amounts were especially likely to be at least 30 times the Medicare allowed amount were California, New York and Texas.
Minnesota was the state included in the review in which the highest out-of-network billed amount was especially likely to be less than 10 times the Medicare allowed amount.