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The risk of unintentional out-of-network encounters with hospital-based physicians at in-network hospitals
YAJEM-56551; No of Pages 6 American Journal of Emergency Medicine xxx (2017) xxx–xxx
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American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
The risk of unintentional out-of-network encounters with hospital-based physicians at in-network hospitals Lawrence H. Brown a,b,⁎, Robert A. Weston a, John E. Gough c a b c
Emergency Medicine Residency Program, Department of Surgery and Perioperative Care, University of Texas-Austin Dell Medical School, Austin, TX, USA Mount Isa Centre for Rural & Remote Health, James Cook University, Townsville, QLD, Australia Department of Emergency Medicine, East Carolina University Brody School of Medicine, Greenville, NC, USA
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Article history: Received 30 January 2017 Received in revised form 14 March 2017 Accepted 16 March 2017 Available online xxxx Keywords: Patient Protection and Affordable Care Act Health insurance Insurance coverage Managed care programs
a b s t r a c t Objective: When hospital-based specialists including emergency physicians, anesthesiologists, pathologists and radiologists are not included in the same insurance networks as their parent hospitals, it creates confusion and leads to unexpected costs for patients. This study explored the frequency with which hospital-based physicians at academic medical centers are not included in the network directories for the same insurance networks as their parent teaching hospitals. Methods: We studied teaching hospitals with residency programs in all four hospital-based specialties. Using insurance plan provider directories, we determined whether each teaching hospital was in-network for randomly selected locally available insurance plans offered through the federal and state marketplace exchanges. For each established hospital-network relationship, we then determined whether hospital-based specialists were included in the provider network directory by searching for the name of each specialty's residency program director and the name of the physician practice group. Results: We identified 79 teaching hospitals participating in 144 locally available insurance plan networks. Hospital-based specialist inclusion in these hospital-network relationships was: emergency physicians: 50.0% (CI: 40%–59%); anesthesiologists: 50.0% (CI: 42%–58%); pathologists: 45.4% (CI: 37%–54%); and radiologists: 55.1% (46%–64%). Inclusion of all four hospital-based specialties occurred in only 45.0% (CI: 36%–54%) of the hospital-network relationships. Conclusion: For insurance plans offered through the federal and state marketplace exchanges, hospital-based specialists frequently are not included in the directories for the insurance networks in which their parent teaching hospitals participate. Further research is needed to explore this issue at non-academic hospitals and for off-exchange insurance products, and to determine effective policy solutions. © 2017 Elsevier Inc. All rights reserved.
1. Introduction The Patient Protection and Affordable Care Act (ACA) [1] greatly increased the number of Americans with health insurance. In 2015, about 11.7 million Americans obtained health insurance through the ACA marketplace exchanges [2]. Most insurers offering ACA plans have created products and networks specifically for the marketplace exchanges [3,4]. The ACA requires these networks to be “sufficient in numbers and types of providers, including providers that specialize in mental health and substance abuse services, to assure that all services will be accessible without unreasonable delay” [1]. However, the network adequacy ⁎ Corresponding author at: UT-Austin Emergency Medicine, 1300 N IH-35, Suite 220, Austin, TX 78701, USA. E-mail addresses: [email protected] (L.H. Brown), [email protected] (R.A. Weston), [email protected] (J.E. Gough).
language of the ACA only applies to qualified health plans offered through the marketplace exchanges, and hospital-based physician services–including emergency medicine, anesthesiology, pathology and radiology–are not specifically addressed in the network adequacy language of the ACA [3-5]. As a result, some patients obtain care at innetwork hospitals only to receive unexpected bills from out-of-network hospital-based physicians providing services in those hospitals [6-9]. This can be particularly likely in emergency situations when patients typically lack the time or necessary resources to determine if a hospital and all of its hospital-based physicians are in their health plan's network [10,11], or when a patient requires care at a tertiary (and often academic) center, such as at a trauma center, heart center or stroke center [12]. Empiric research on network adequacy, inclusiveness of provider directories, and unintentional out-of-network experiences is limited [10], and has largely focused on unintentional out-of-network encounters with emergency physicians [7-9,11]. We undertook this study to
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Please cite this article as: Brown LH, et al, The risk of unintentional out-of-network encounters with hospital-based physicians at in-network hospitals, American Journal of Emergency Medicine (2017), http://dx.doi.org/10.1016/j.ajem.2017.03.033
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L.H. Brown et al. / American Journal of Emergency Medicine xxx (2017) xxx–xxx
quantitatively evaluate the frequency of network directory inclusion for all four traditionally hospital-based specialists at in-network teaching hospitals. We hypothesized that the frequency of inclusion in the network directories would not vary by specialty, or by insurance exchange (federal or state), network type, or plan metal level. 2. Methods This was a cross-sectional study using existing publicly available data for calendar year 2015. We studied all teaching hospitals with established residency programs in all four traditionally hospital-based specialties–emergency medicine, anesthesiology, pathology, and radiology–so that we could definitively identify specialty physician and practice group names for each specialty. We studied insurance plans offered through the federal and state marketplace exchanges so that we could identify plan availability, plan characteristics and hospital and physician network participation using publicly available data. 2.1. Identification of teaching hospitals We identified all teaching hospitals with established residency programs in all four traditionally hospital-based specialties using Accreditation Council for Graduate Medical Education (ACGME) lists of approved residency programs [13-16]. We limited the analysis to the primary teaching site for each residency program and excluded newly accredited programs not yet accepting residents. 2.2. Selection of insurance networks The Center for Medicare and Medicaid Services (CMS) maintains public use files listing all federal health exchange insurance plans offered in each county of each participating state [17]. We matched the ZIP code of each included teaching hospitals with these data to identify
all of the federal health exchange plans available for 2015 in the same county as the teaching hospital. For hospitals in states that maintain their own health exchanges, we identified the plans available in each teaching hospital's home county using public use data or plan lists from the state exchange websites. For two states without a public database or listing of available plans, we used the health exchange's online navigator to identify available plans for a hypothetical 30 year old, non-smoking male residing in the same county as the teaching hospital. We collated all the plan data in a single Excel spreadsheet, including: 1) the insurer; 2) plan marketing name; 3) network type; and 4) plan metal level (Bronze, Silver, Gold, Platinum). For each teaching hospital, we then used the Excel random number function to randomly select up to four locally available plans–one for each type of network (HMO, PPO, EPO, POS)–without regard to plan metal level. 2.3. Determination of hospital and hospital-based specialist network participation We searched the online provider directory for each selected insurance plan to determine if the corresponding teaching hospital was listed as in-network. If no hospital-network relationship existed, we excluded that potential relationship from further analysis. Where hospitals were in-network for the selected insurance plan(s), we identified hospital-based specialists at those hospitals two ways. First, we obtained the name of each hospital-based specialty's residency program director from the ACGME residency program information. Second, recognizing the limitations of searching for a single physician name and that some network directories might collectively identify hospitalbased specialists by the name of their practice group rather than individually, we used the online CMS “Medicare Provider Directory” [18] to determine the business name of the academic practice group for each included residency program. When possible, we also used the American College of Emergency Physician's practice group directory
Fig. 1. Study design and primary results.
Please cite this article as: Brown LH, et al, The risk of unintentional out-of-network encounters with hospital-based physicians at in-network hospitals, American Journal of Emergency Medicine (2017), http://dx.doi.org/10.1016/j.ajem.2017.03.033
L.H. Brown et al. / American Journal of Emergency Medicine xxx (2017) xxx–xxx
[19] to identify the business name for emergency medicine group practices that were not included in the Medicare Provider Directory. For each confirmed hospital-network relationship, we searched the insurer's network provider directory to determine if each hospitalbased specialty's residency program director was included as an in-network provider. If the residency director was not individually listed in the provider directory, the directory was searched again to determine if the practice group was listed as in-network. We used a liberal approach to determining practice group inclusion in the network directory: if the practice group name was “XYZ University Medical Group” and the network directory listed “XYZ University Physicians Group” as innetwork, we assumed those were the same practice groups. If either the residency director or the practice group was included in the provider directory, hospital-based physicians of that specialty were considered in-network. The directory searching was shared by the investigators. To evaluate inter-rater reliability, two investigators determined inclusion of the hospital-based specialists in the network directories for a randomly selected 10% sub-sample of the confirmed hospital-network relationships.
Table 1 Plan and network characteristics, N (%).
Overall Exchange Federal State Network type HMO PPO EPO POS Other Metal level Bronze Silver Gold Platinum Catastrophic a
2.4. Analysis We determined the frequency of inclusion in the provider directories for each specialty separately, and the frequency with which all four hospital-based specialties at in-network teaching hospitals were included in the respective provider directories. We used Kappa as a measure of inter-rater agreement for determinations of directory inclusion. We compared the frequency of inclusion among the different specialties using chi-squared analysis (×2); we also compared the frequency of complete inclusion of all four specialties among the various network types, plan metal levels, and source exchanges (federal vs. state) using ×2, Fisher's Exact Test, or ×2 for trend as appropriate. A two-sided p-value b 0.05 was used to establish statistical significance. An a priori power calculation indicated that a sample of 120 established hospital-network relationships would allow us to calculate confidence intervals for proportions of approximately ±10%, and to detect substantial (e.g., 50% vs. 70%) differences in the frequency of directory inclusion among different specialties, network types, and/or plan metal levels. 2.5. Human subjects review
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Uniquea federal and state exchange plans available to included teaching hospitals
Randomly Plans for selected established plans hospital-network relationships
2612
235
144
2144 (82.1) 468 (17.9)
155 (66.0) 80 (34.0)
96 (66.7) 48 (33.3)
1143 (43.8) 926 (35.5) 251 (9.6) 208 (8.0) 84 (3.2)
76 (32.3) 75 (31.9) 35 (14.9) 43 (18.3) 6 (2.6)
47 (32.6) 50 (34.7) 19 (13.2) 28 (19.4) 0 (0.0)
1112 (28.1) 1501 (38.0) 904 (22.9) 241 (6.1) 196 (4.9)
73 (31.1) 87 (37.0) 56 (23.8) 19 (8.1) 0 (0.0)
45 (31.3) 54 (37.5) 36 (25.0) 9 (6.3) 0 (0.0)
Many plans were available in more than one county.
3.1. Inclusion of hospital-based specialists Inclusion in the network directory could not be reliably assessed for 18 emergency medicine, six radiology and three pathology observations (e.g., unable to identify practice group name; unable to access directory). Table 2 shows the proportion of directories for the assessable hospital-network relationships that included each of the hospital-based specialists. Inter-rater agreement for determination of hospital-based specialist inclusion in the provider directories was 93% (Kappa = 0.83). At least one hospital-based specialist was included in the directories for 91 (63.2%, CI: 55%–71%) of the 144 hospital-network relationships. Emergency medicine was included in 63 (50.0%, CI: 40%–59%) of the provider directories for 126 assessable hospital-network relationships; anesthesiology in 72 (50.0%, CI: 42%–58%) of 144 assessable relationships; pathology in 64 (45.4%, CI: 37%–54%) of 141 assessable relationships; and radiology in 76 (55.1%, CI: 46%–64%) of 138 assessable relationships. Inclusion of all four hospital-based specialties occurred in 54 (45.0%, CI: 36%–54%) of the directories for the 120 fully assessable hospital-network relationships.
The Institutional Review Board determined that this study was not “human subjects research” as defined by 45 CFR 46. 3.2. Network inclusion by specialty and plan characteristics 3. Results In 2015, eighty-seven hospitals offered residencies in all four hospital-based specialties. Of the 2612 exchange insurance plans available in the respective counties, 235 (9%) were randomly selected for this analysis. Hospital participation was confirmed for 79 teaching hospitals (91%) in 34 states plus Washington, D.C participating in 128 (55%) of the 235 randomly selected locally available insurance plan networks. Most hospitals participated in more than one randomly selected plan, and some plan networks included more than one teaching hospital, resulting in a total of 144 individual hospital-network relationships (Fig. 1). Table 1 shows the network characteristics of all the exchange health plans available in the same counties as the 87 teaching hospitals with residency programs in all four traditionally hospital-based specialties, the 235 health plans randomly selected for inclusion in this study, and the plans for the 144 established hospital-network relationships. Our methodology resulted in over-sampling of EPO and POS plans, but otherwise the plans for the established hospital-network relationships were reasonably representative of the plans available in our study counties and all the plans available on the exchange.
There were no significant differences in the frequency of network directory inclusion across the four hospital-based specialties (p = 0.46). There were also no significant differences in network directory inclusion for plans offered through the federal versus state exchanges, either within each specialty (emergency medicine, p = 0.71; anesthesiology, p = 0.48; pathology, p = 0.84; radiology, p = 0.10) or across all four specialties (federal, p = 0.83; state, p = 0.28). Within each network type the frequency of directory inclusion did not differ for the four hospital-based specialties (HMO, p = 0.51; PPO, p = 0.80; EPO, p = 0.99; Point of Service (POS), p = 0.83). However, EPO network directories were more likely than other network directories to include hospital-based physicians (emergency medicine, p = 0.006; anesthesiology, p = 0.02; pathology, p = 0.001; radiology, p = 0.004; all four specialties, p = 0.009), and POS network directories were less likely than other network directories to include pathologists (p = 0.001), radiologists (p = 0.004) or all four hospital-based specialties (p = 0.009). Similarly, within each plan metal level the frequency of directory inclusion did not differ for the four hospital-based specialties (Bronze, p = 0.53; Silver, p = 0.55; Gold, p = 0.99; Platinum, p = 0.99), but the
Please cite this article as: Brown LH, et al, The risk of unintentional out-of-network encounters with hospital-based physicians at in-network hospitals, American Journal of Emergency Medicine (2017), http://dx.doi.org/10.1016/j.ajem.2017.03.033
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L.H. Brown et al. / American Journal of Emergency Medicine xxx (2017) xxx–xxx
Table 2 Inclusion of hospital based specialists by plan and network characteristics, N (%).
N assessable Specialists included by Exchange Federal State by Network type HMO PPO EPO POS by Metal level Bronze Silver Gold Platinum
Emergency
Anesthesiology
Pathology
Radiology
All four
126 63 (50.0)
144 72 (50.0)
141 64 (45.4)
138 76 (55.1)
120 54 (45.0)
43 (51.2) 20 (47.6)
46 (47.9) 26 (54.2)
43 (44.8) 21 (46.7)
45 (50.0) 31 (64.6)
35 (43.8) 19 (47.5)
17 (40.5) 24 (57.1) 15 (78.9)a 7 (30.4)
22 (46.8) 26 (52.0) 15 (78.9)a 9 (32.1)
18 (39.1) 25 (52.1) 15 (78.9)a 6 (21.4)b
24 (53.3) 29 (60.4) 15 (83.3)a 8 (29.6)b
15 (37.5) 22 (55.0) 12 (66.7)a 5 (22.7)b
19 (46.3) 21 (45.7) 17 (56.7) 6 (66.7)
18 (40.0)c 27 (50.0) 20 (55.6) 7 (77.8)
16 (35.6)c 23 (43.4) 19 (55.9) 6 (66.7)
21 (50.0) 30 (56.6) 18 (52.9) 7 (77.8)
12 (31.6)d 20 (45.5) 16 (55.2) 6 (66.7)
HMO = health maintenance organization; PPO = preferred provider organization; EPO = exclusive provider organization; POS = point of service. a EPO N HMO, PPO & POS (chi square (×2), p b 0.05). b POS b HMO, PPO & EPO (×2, p b 0.05). c Directory inclusion increases with metal level for anesthesiology and for pathology (×2 for trend, p b 0.05). d Inclusion of all four specialties increases with metal level (×2 for trend, p b 0.05).
frequency of directory inclusion for anesthesiology (p = 0.03), pathology (p = 0.03) and all four hospital-based specialists (p = 0.02) trended upward with increasing plan metal level. 4. Discussion To our knowledge, this is the first effort to measure inclusion of the four traditionally hospital-based specialists in the provider directories for a broad sample of insurance plan networks. Inclusion ranged from 45.4% for pathology to 55.1% for radiology. Only 45% of studied plan directories included all four hospital-based specialties. These findings highlight that patients who seek care at academic medical centers could find it difficult to prospectively identify in-network teaching hospitals where hospital-based specialists can be definitively determined to be in-network, putting them at risk for unintentional out-of-network physician encounters. This study also clarifies that this phenomenon is not predominantly attributable to out-of-network emergency physicians. We studied insurance plans offered through the federal and state marketplace exchanges, but the problem of out-of-network hospitalbased specialists is not unique to exchange insurance plans. A 2011 pre-ACA national survey found 3.2% of beneficiaries in private health plans had experienced an unintentional out-of-network contact [20]. Among plans offered by the three insurers with the greatest market share in Texas, between 21% and 56% of in-network hospitals had no in-network emergency physicians in 2013–2014; for anesthesiology, radiology and pathology, those numbers were as high as 20% to 38% [21]. A recent analysis of claims data from one large commercial insurer found 22% of emergency department visits at in-network hospitals involved out-of-network emergency physicians [11]. The increased numbers of insured patients under the ACA has only served to highlight the issues around network adequacy. We cannot estimate from our data the dollar amount or proportion of hospital-based specialist charges that patients might be expected to bear when they experience unintentional out-of-network care at an in-network teaching hospitals, but those costs are likely substantial [11]. Insurance plans cannot impose higher copayments or co-insurance for out-of-network emergency care, and they must fairly determine the amount they pay out-of-network providers for services rendered at innetwork hospitals [1]. The ACA does not, however, absolve patients from responsibility for any amount that is not covered by the insurer, [5,22] nor does it require that those additional patient-borne costs count toward the beneficiary's deductible or out-of-pocket maximum [3,4]. CMS has proposed standards that would require insurers to
count beneficiaries' cost sharing for essential services from an out-ofnetwork provider in an otherwise in-network setting toward their annual out-of-pocket maximum, but the proposal would not apply to balance billing, or to HMO or EPO plans that do not cover any nonemergency out-of-network services [23]. We found EPO network directories were more likely to include hospital-based specialists, and some evidence of increasing hospital-based specialist inclusion with increasing plan metal level. Knowing this, informed beneficiaries might be inspired to pay higher premiums for plans with broader networks, but broader networks and higher-level plans do not guarantee inclusion of hospital-based physicians. In our data, only 66.7% of EPO network plan directories and 55.2% of Gold plan directories included all four hospital-based specialists. Given the complexity of evaluating and selecting an insurance plan, many buyers on the marketplace exchanges simply choose the cheapest available plan [24], and this appears to be true across all plan metal levels. Even among purchasers of gold and platinum tier plans, approximately 78% of consumers choose narrow-network plans [25]. Individuals insured through their employer or other group plans have little–if any–choice regarding network breadth. For patients, there is little transparency about incomplete network participation, inconsistency in when and how physicians disclose their out-of-network status and its implications on patient-borne costs, and no clear process for resolving disputes about unexpected charges resulting from unintentional out-of-network care 10. This requires policy solutions that protect patients without unfairly eroding the negotiating position of hospital-based physicians, while enabling insurers to contain costs. Some potential solutions are detailed in Table 3. These loosely fit into five themes [1]: new or additional regulations regarding network adequacy [2]; improved beneficiary education [3]; transparency regarding network participation [4]; financial protections for patients; and [5] mediation. The current efforts to revise or replace the ACA offer an opportunity for policy solutions addressing network adequacy across all health insurance products. 4.1. Limitations We studied hospital-based specialists' inclusion in insurance plan network directories, which might not fully represent hospital-based specialists' actual participation in networks [26]. Indeed, some network directories completely omit hospital-based specialists: one recent analysis found 22% of directories for marketplace insurance plans lacked any emergency physicians [27]. The online directories are sometimes difficult to navigate and that too might have affected our ability to identify
Please cite this article as: Brown LH, et al, The risk of unintentional out-of-network encounters with hospital-based physicians at in-network hospitals, American Journal of Emergency Medicine (2017), http://dx.doi.org/10.1016/j.ajem.2017.03.033
L.H. Brown et al. / American Journal of Emergency Medicine xxx (2017) xxx–xxx Table 3 Potential policy solutions. Regulatory
Education
Transparency
Policy makers should more fully define network adequacy, and specifically address inclusion of (or reimbursement for) hospital-based physicians [3,5]. Plan and network marketing materials should be required to include some measure of network breadth and clearly disclose non-inclusion of hospital-based specialists at in-network hospitals [4]. Policy makers, regulators and insurers should provide outreach education to beneficiaries that specifically addresses the issue of unintentional use of out-of-network hospital-based specialists at in-network hospitals [21]. Insurers should include participating hospital-based physicians (or physician groups) in their network provider directories. Hospitals and hospital-based physicians should develop mechanisms to inform patients about their network status. This requires that hospital-based physicians know—or be quickly able to determine—their own network status for various insurance plans [3,5].
Patient Protections
Hospitals and hospital based-physicians should develop mechanisms to inform patients about the costs (or approximate costs) of out-of-network care that they provide before that care is provided [5]. States that provide protections for patients should align the protections for patients in HMO, PPO, EPO and other networks [5,21]. The patient burden for unintentional out-of-network care at in-network hospitals should be no more than their share of the costs for in-network care for the same services [3,5,21].
Mediation
Patient-borne costs for out-of-network care received from hospital-based physicians at in-network hospitals should be counted toward their annual deductible and out-of-pocket maximum [3,5]. Disputes about reimbursement for unintentional out-of-network care should be mediated between insurers and providers, not patients [21].
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network directory—or vice-versa. Also, searching for only the residency director by name likely reduced our ability to identify hospital-based physicians at some hospitals as in-network. For comparison, however, we were able to identify 86.5% of surgery and 89.6% of family practice residency directors at these same teaching hospitals as in-network using the same single-name search methodology. We did search for variations of names, but we could not search for every possible variation. Finally, we did not include hospitalists or neonatologists in our study, although they too are hospital-based specialists who might not be included in the same networks as their parent teaching hospitals [5]. 5. Conclusion The most optimistic interpretation of these data is that patients insured through the ACA exchange insurance plans could find it difficult to identify in-network teaching hospitals where all of the hospitalbased specialists are also in-network. The pessimistic interpretation is that hospital-based specialists frequently are not included in the directories for the insurance networks in which their parent teaching hospitals participate. In either case, these data establish that patients seeking care at in-network academic medical centers could be at significant risk for unintentional out-of-network physician encounters, and that risk is roughly equal across the specialties of emergency medicine, anesthesiology, pathology and radiology. Further research is needed to explore this issue in off-exchange insurance plans and at non-academic hospitals, and to determine the most effective policy solutions for addressing the problem. Acknowledgements The authors have no conflicts of interest with regards to the content of this manuscript. This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors. References
in-network hospital-based physicians, but that would be equally true for all four of the specialties we studied—and for patients attempting to identify in-network physicians. CMS does not provide subscriber data that would allow us to weight our analysis by market penetration, and some of the plans included in our analysis could have relatively few subscribers. However, a post-hoc analysis including only those plans offered by large nationwide insurers (Aetna; Blue Cross/Blue Shield companies; Humana; Kaiser, United Healthcare) produced results only slightly better than those of our primary analysis (emergency medicine: 53.5%; anesthesiology: 52.3%; pathology: 47.7%; radiology: 62.9%; all four specialties: 51.7%). We studied teaching hospitals because for the convenience of data availability, but also because they are more likely to be large tertiary care facilities with specialty services, they are typically perceived as centers that provide exemplary care, and they often serve as the “safety net” in the communities they serve. These data might not be generalizable to non-academic settings. Narrow networks are less likely than broad networks to include academic medical centers [28], the financial incentives for network participation might not be the same for academic versus private practice groups, and reimbursement levels impact academic groups differently than private practice groups [29,30]. Whether those factors result in greater or lesser network participation by hospital-based physicians at non-teaching hospitals will require further research; one could construct a theoretical argument for either effect. We used inclusion of the residency director or the academic practice group in the insurance plans' network directories as our measure of network inclusion of hospital-based physicians. If there had been a recent change in residency director or practice group name, it is possible that the ACGME or CMS data updated more quickly than the insurers'
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[23] Pollitz K. Surprise medical bills. Henry J. Kaiser Foundation; 17 March 2016(Accessed November 16, 2016) http://kff.org/private-insurance/issue-brief/ surprise-medical-bills/. [24] Ericson KM, Starc A. Heuristics and heterogeneity in health insurance exchanges: evidence from the Massachusetts connector. Am Econ Rev 2012;102(3):493–7. [25] Bauman N, Chopra M, Cordina J, Meyer J, Sutaria S. Winning strategies for participating in narrow-network exchange offerings. New York, NY: McKinsey & Company; 2014(Accessed April 23, 2015) http://healthcare.mckinsey.com/winning-strategies-participating-narrow-network-exchange-offerings. [26] Tahir D. Inaccurate provider directories blamed on weak tech, network churn. Mod Healthc 11 December 2014 (Accessed October 12, 2016) http://www. modernhealthcare.com/article/20141211/NEWS/312119927. [27] Dorner SC, Camargo CA, Schuur JD, Raja AS. Access to in-network emergency physicians and emergency departments within federally qualified health plans in 2015. West J Emerg Med 2016;17(1):18–21. [28] Anonymous. Hospital networks: updated national view on configurations on the exchanges. New York, NY: McKinsey & Company; 2014. [29] Levitt SH. Impact of managed care on scholarly activity and patient care: case study of 12 academic radiology and radiation oncology departments. Radiology 2000; 216(3):618–23. [30] Reich DL, Galati M. American and European anesthesia reimbursement policies' effects on the adoption of novel techniques. J Cardiothorac Vasc Anesth 2009;23(2): 140–1.
Please cite this article as: Brown LH, et al, The risk of unintentional out-of-network encounters with hospital-based physicians at in-network hospitals, American Journal of Emergency Medicine (2017), http://dx.doi.org/10.1016/j.ajem.2017.03.033
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
The risk of unintentional out-of-network encounters with hospital-based physicians at in-network hospitals Lawrence H. Brown a,b,⁎, Robert A. Weston a, John E. Gough c a b c
Emergency Medicine Residency Program, Department of Surgery and Perioperative Care, University of Texas-Austin Dell Medical School, Austin, TX, USA Mount Isa Centre for Rural & Remote Health, James Cook University, Townsville, QLD, Australia Department of Emergency Medicine, East Carolina University Brody School of Medicine, Greenville, NC, USA
a r t i c l e
i n f o
Article history: Received 30 January 2017 Received in revised form 14 March 2017 Accepted 16 March 2017 Available online xxxx Keywords: Patient Protection and Affordable Care Act Health insurance Insurance coverage Managed care programs
a b s t r a c t Objective: When hospital-based specialists including emergency physicians, anesthesiologists, pathologists and radiologists are not included in the same insurance networks as their parent hospitals, it creates confusion and leads to unexpected costs for patients. This study explored the frequency with which hospital-based physicians at academic medical centers are not included in the network directories for the same insurance networks as their parent teaching hospitals. Methods: We studied teaching hospitals with residency programs in all four hospital-based specialties. Using insurance plan provider directories, we determined whether each teaching hospital was in-network for randomly selected locally available insurance plans offered through the federal and state marketplace exchanges. For each established hospital-network relationship, we then determined whether hospital-based specialists were included in the provider network directory by searching for the name of each specialty's residency program director and the name of the physician practice group. Results: We identified 79 teaching hospitals participating in 144 locally available insurance plan networks. Hospital-based specialist inclusion in these hospital-network relationships was: emergency physicians: 50.0% (CI: 40%–59%); anesthesiologists: 50.0% (CI: 42%–58%); pathologists: 45.4% (CI: 37%–54%); and radiologists: 55.1% (46%–64%). Inclusion of all four hospital-based specialties occurred in only 45.0% (CI: 36%–54%) of the hospital-network relationships. Conclusion: For insurance plans offered through the federal and state marketplace exchanges, hospital-based specialists frequently are not included in the directories for the insurance networks in which their parent teaching hospitals participate. Further research is needed to explore this issue at non-academic hospitals and for off-exchange insurance products, and to determine effective policy solutions. © 2017 Elsevier Inc. All rights reserved.
1. Introduction The Patient Protection and Affordable Care Act (ACA) [1] greatly increased the number of Americans with health insurance. In 2015, about 11.7 million Americans obtained health insurance through the ACA marketplace exchanges [2]. Most insurers offering ACA plans have created products and networks specifically for the marketplace exchanges [3,4]. The ACA requires these networks to be “sufficient in numbers and types of providers, including providers that specialize in mental health and substance abuse services, to assure that all services will be accessible without unreasonable delay” [1]. However, the network adequacy ⁎ Corresponding author at: UT-Austin Emergency Medicine, 1300 N IH-35, Suite 220, Austin, TX 78701, USA. E-mail addresses: [email protected] (L.H. Brown), [email protected] (R.A. Weston), [email protected] (J.E. Gough).
language of the ACA only applies to qualified health plans offered through the marketplace exchanges, and hospital-based physician services–including emergency medicine, anesthesiology, pathology and radiology–are not specifically addressed in the network adequacy language of the ACA [3-5]. As a result, some patients obtain care at innetwork hospitals only to receive unexpected bills from out-of-network hospital-based physicians providing services in those hospitals [6-9]. This can be particularly likely in emergency situations when patients typically lack the time or necessary resources to determine if a hospital and all of its hospital-based physicians are in their health plan's network [10,11], or when a patient requires care at a tertiary (and often academic) center, such as at a trauma center, heart center or stroke center [12]. Empiric research on network adequacy, inclusiveness of provider directories, and unintentional out-of-network experiences is limited [10], and has largely focused on unintentional out-of-network encounters with emergency physicians [7-9,11]. We undertook this study to
http://dx.doi.org/10.1016/j.ajem.2017.03.033 0735-6757/© 2017 Elsevier Inc. All rights reserved.
Please cite this article as: Brown LH, et al, The risk of unintentional out-of-network encounters with hospital-based physicians at in-network hospitals, American Journal of Emergency Medicine (2017), http://dx.doi.org/10.1016/j.ajem.2017.03.033
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quantitatively evaluate the frequency of network directory inclusion for all four traditionally hospital-based specialists at in-network teaching hospitals. We hypothesized that the frequency of inclusion in the network directories would not vary by specialty, or by insurance exchange (federal or state), network type, or plan metal level. 2. Methods This was a cross-sectional study using existing publicly available data for calendar year 2015. We studied all teaching hospitals with established residency programs in all four traditionally hospital-based specialties–emergency medicine, anesthesiology, pathology, and radiology–so that we could definitively identify specialty physician and practice group names for each specialty. We studied insurance plans offered through the federal and state marketplace exchanges so that we could identify plan availability, plan characteristics and hospital and physician network participation using publicly available data. 2.1. Identification of teaching hospitals We identified all teaching hospitals with established residency programs in all four traditionally hospital-based specialties using Accreditation Council for Graduate Medical Education (ACGME) lists of approved residency programs [13-16]. We limited the analysis to the primary teaching site for each residency program and excluded newly accredited programs not yet accepting residents. 2.2. Selection of insurance networks The Center for Medicare and Medicaid Services (CMS) maintains public use files listing all federal health exchange insurance plans offered in each county of each participating state [17]. We matched the ZIP code of each included teaching hospitals with these data to identify
all of the federal health exchange plans available for 2015 in the same county as the teaching hospital. For hospitals in states that maintain their own health exchanges, we identified the plans available in each teaching hospital's home county using public use data or plan lists from the state exchange websites. For two states without a public database or listing of available plans, we used the health exchange's online navigator to identify available plans for a hypothetical 30 year old, non-smoking male residing in the same county as the teaching hospital. We collated all the plan data in a single Excel spreadsheet, including: 1) the insurer; 2) plan marketing name; 3) network type; and 4) plan metal level (Bronze, Silver, Gold, Platinum). For each teaching hospital, we then used the Excel random number function to randomly select up to four locally available plans–one for each type of network (HMO, PPO, EPO, POS)–without regard to plan metal level. 2.3. Determination of hospital and hospital-based specialist network participation We searched the online provider directory for each selected insurance plan to determine if the corresponding teaching hospital was listed as in-network. If no hospital-network relationship existed, we excluded that potential relationship from further analysis. Where hospitals were in-network for the selected insurance plan(s), we identified hospital-based specialists at those hospitals two ways. First, we obtained the name of each hospital-based specialty's residency program director from the ACGME residency program information. Second, recognizing the limitations of searching for a single physician name and that some network directories might collectively identify hospitalbased specialists by the name of their practice group rather than individually, we used the online CMS “Medicare Provider Directory” [18] to determine the business name of the academic practice group for each included residency program. When possible, we also used the American College of Emergency Physician's practice group directory
Fig. 1. Study design and primary results.
Please cite this article as: Brown LH, et al, The risk of unintentional out-of-network encounters with hospital-based physicians at in-network hospitals, American Journal of Emergency Medicine (2017), http://dx.doi.org/10.1016/j.ajem.2017.03.033
L.H. Brown et al. / American Journal of Emergency Medicine xxx (2017) xxx–xxx
[19] to identify the business name for emergency medicine group practices that were not included in the Medicare Provider Directory. For each confirmed hospital-network relationship, we searched the insurer's network provider directory to determine if each hospitalbased specialty's residency program director was included as an in-network provider. If the residency director was not individually listed in the provider directory, the directory was searched again to determine if the practice group was listed as in-network. We used a liberal approach to determining practice group inclusion in the network directory: if the practice group name was “XYZ University Medical Group” and the network directory listed “XYZ University Physicians Group” as innetwork, we assumed those were the same practice groups. If either the residency director or the practice group was included in the provider directory, hospital-based physicians of that specialty were considered in-network. The directory searching was shared by the investigators. To evaluate inter-rater reliability, two investigators determined inclusion of the hospital-based specialists in the network directories for a randomly selected 10% sub-sample of the confirmed hospital-network relationships.
Table 1 Plan and network characteristics, N (%).
Overall Exchange Federal State Network type HMO PPO EPO POS Other Metal level Bronze Silver Gold Platinum Catastrophic a
2.4. Analysis We determined the frequency of inclusion in the provider directories for each specialty separately, and the frequency with which all four hospital-based specialties at in-network teaching hospitals were included in the respective provider directories. We used Kappa as a measure of inter-rater agreement for determinations of directory inclusion. We compared the frequency of inclusion among the different specialties using chi-squared analysis (×2); we also compared the frequency of complete inclusion of all four specialties among the various network types, plan metal levels, and source exchanges (federal vs. state) using ×2, Fisher's Exact Test, or ×2 for trend as appropriate. A two-sided p-value b 0.05 was used to establish statistical significance. An a priori power calculation indicated that a sample of 120 established hospital-network relationships would allow us to calculate confidence intervals for proportions of approximately ±10%, and to detect substantial (e.g., 50% vs. 70%) differences in the frequency of directory inclusion among different specialties, network types, and/or plan metal levels. 2.5. Human subjects review
3
Uniquea federal and state exchange plans available to included teaching hospitals
Randomly Plans for selected established plans hospital-network relationships
2612
235
144
2144 (82.1) 468 (17.9)
155 (66.0) 80 (34.0)
96 (66.7) 48 (33.3)
1143 (43.8) 926 (35.5) 251 (9.6) 208 (8.0) 84 (3.2)
76 (32.3) 75 (31.9) 35 (14.9) 43 (18.3) 6 (2.6)
47 (32.6) 50 (34.7) 19 (13.2) 28 (19.4) 0 (0.0)
1112 (28.1) 1501 (38.0) 904 (22.9) 241 (6.1) 196 (4.9)
73 (31.1) 87 (37.0) 56 (23.8) 19 (8.1) 0 (0.0)
45 (31.3) 54 (37.5) 36 (25.0) 9 (6.3) 0 (0.0)
Many plans were available in more than one county.
3.1. Inclusion of hospital-based specialists Inclusion in the network directory could not be reliably assessed for 18 emergency medicine, six radiology and three pathology observations (e.g., unable to identify practice group name; unable to access directory). Table 2 shows the proportion of directories for the assessable hospital-network relationships that included each of the hospital-based specialists. Inter-rater agreement for determination of hospital-based specialist inclusion in the provider directories was 93% (Kappa = 0.83). At least one hospital-based specialist was included in the directories for 91 (63.2%, CI: 55%–71%) of the 144 hospital-network relationships. Emergency medicine was included in 63 (50.0%, CI: 40%–59%) of the provider directories for 126 assessable hospital-network relationships; anesthesiology in 72 (50.0%, CI: 42%–58%) of 144 assessable relationships; pathology in 64 (45.4%, CI: 37%–54%) of 141 assessable relationships; and radiology in 76 (55.1%, CI: 46%–64%) of 138 assessable relationships. Inclusion of all four hospital-based specialties occurred in 54 (45.0%, CI: 36%–54%) of the directories for the 120 fully assessable hospital-network relationships.
The Institutional Review Board determined that this study was not “human subjects research” as defined by 45 CFR 46. 3.2. Network inclusion by specialty and plan characteristics 3. Results In 2015, eighty-seven hospitals offered residencies in all four hospital-based specialties. Of the 2612 exchange insurance plans available in the respective counties, 235 (9%) were randomly selected for this analysis. Hospital participation was confirmed for 79 teaching hospitals (91%) in 34 states plus Washington, D.C participating in 128 (55%) of the 235 randomly selected locally available insurance plan networks. Most hospitals participated in more than one randomly selected plan, and some plan networks included more than one teaching hospital, resulting in a total of 144 individual hospital-network relationships (Fig. 1). Table 1 shows the network characteristics of all the exchange health plans available in the same counties as the 87 teaching hospitals with residency programs in all four traditionally hospital-based specialties, the 235 health plans randomly selected for inclusion in this study, and the plans for the 144 established hospital-network relationships. Our methodology resulted in over-sampling of EPO and POS plans, but otherwise the plans for the established hospital-network relationships were reasonably representative of the plans available in our study counties and all the plans available on the exchange.
There were no significant differences in the frequency of network directory inclusion across the four hospital-based specialties (p = 0.46). There were also no significant differences in network directory inclusion for plans offered through the federal versus state exchanges, either within each specialty (emergency medicine, p = 0.71; anesthesiology, p = 0.48; pathology, p = 0.84; radiology, p = 0.10) or across all four specialties (federal, p = 0.83; state, p = 0.28). Within each network type the frequency of directory inclusion did not differ for the four hospital-based specialties (HMO, p = 0.51; PPO, p = 0.80; EPO, p = 0.99; Point of Service (POS), p = 0.83). However, EPO network directories were more likely than other network directories to include hospital-based physicians (emergency medicine, p = 0.006; anesthesiology, p = 0.02; pathology, p = 0.001; radiology, p = 0.004; all four specialties, p = 0.009), and POS network directories were less likely than other network directories to include pathologists (p = 0.001), radiologists (p = 0.004) or all four hospital-based specialties (p = 0.009). Similarly, within each plan metal level the frequency of directory inclusion did not differ for the four hospital-based specialties (Bronze, p = 0.53; Silver, p = 0.55; Gold, p = 0.99; Platinum, p = 0.99), but the
Please cite this article as: Brown LH, et al, The risk of unintentional out-of-network encounters with hospital-based physicians at in-network hospitals, American Journal of Emergency Medicine (2017), http://dx.doi.org/10.1016/j.ajem.2017.03.033
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Table 2 Inclusion of hospital based specialists by plan and network characteristics, N (%).
N assessable Specialists included by Exchange Federal State by Network type HMO PPO EPO POS by Metal level Bronze Silver Gold Platinum
Emergency
Anesthesiology
Pathology
Radiology
All four
126 63 (50.0)
144 72 (50.0)
141 64 (45.4)
138 76 (55.1)
120 54 (45.0)
43 (51.2) 20 (47.6)
46 (47.9) 26 (54.2)
43 (44.8) 21 (46.7)
45 (50.0) 31 (64.6)
35 (43.8) 19 (47.5)
17 (40.5) 24 (57.1) 15 (78.9)a 7 (30.4)
22 (46.8) 26 (52.0) 15 (78.9)a 9 (32.1)
18 (39.1) 25 (52.1) 15 (78.9)a 6 (21.4)b
24 (53.3) 29 (60.4) 15 (83.3)a 8 (29.6)b
15 (37.5) 22 (55.0) 12 (66.7)a 5 (22.7)b
19 (46.3) 21 (45.7) 17 (56.7) 6 (66.7)
18 (40.0)c 27 (50.0) 20 (55.6) 7 (77.8)
16 (35.6)c 23 (43.4) 19 (55.9) 6 (66.7)
21 (50.0) 30 (56.6) 18 (52.9) 7 (77.8)
12 (31.6)d 20 (45.5) 16 (55.2) 6 (66.7)
HMO = health maintenance organization; PPO = preferred provider organization; EPO = exclusive provider organization; POS = point of service. a EPO N HMO, PPO & POS (chi square (×2), p b 0.05). b POS b HMO, PPO & EPO (×2, p b 0.05). c Directory inclusion increases with metal level for anesthesiology and for pathology (×2 for trend, p b 0.05). d Inclusion of all four specialties increases with metal level (×2 for trend, p b 0.05).
frequency of directory inclusion for anesthesiology (p = 0.03), pathology (p = 0.03) and all four hospital-based specialists (p = 0.02) trended upward with increasing plan metal level. 4. Discussion To our knowledge, this is the first effort to measure inclusion of the four traditionally hospital-based specialists in the provider directories for a broad sample of insurance plan networks. Inclusion ranged from 45.4% for pathology to 55.1% for radiology. Only 45% of studied plan directories included all four hospital-based specialties. These findings highlight that patients who seek care at academic medical centers could find it difficult to prospectively identify in-network teaching hospitals where hospital-based specialists can be definitively determined to be in-network, putting them at risk for unintentional out-of-network physician encounters. This study also clarifies that this phenomenon is not predominantly attributable to out-of-network emergency physicians. We studied insurance plans offered through the federal and state marketplace exchanges, but the problem of out-of-network hospitalbased specialists is not unique to exchange insurance plans. A 2011 pre-ACA national survey found 3.2% of beneficiaries in private health plans had experienced an unintentional out-of-network contact [20]. Among plans offered by the three insurers with the greatest market share in Texas, between 21% and 56% of in-network hospitals had no in-network emergency physicians in 2013–2014; for anesthesiology, radiology and pathology, those numbers were as high as 20% to 38% [21]. A recent analysis of claims data from one large commercial insurer found 22% of emergency department visits at in-network hospitals involved out-of-network emergency physicians [11]. The increased numbers of insured patients under the ACA has only served to highlight the issues around network adequacy. We cannot estimate from our data the dollar amount or proportion of hospital-based specialist charges that patients might be expected to bear when they experience unintentional out-of-network care at an in-network teaching hospitals, but those costs are likely substantial [11]. Insurance plans cannot impose higher copayments or co-insurance for out-of-network emergency care, and they must fairly determine the amount they pay out-of-network providers for services rendered at innetwork hospitals [1]. The ACA does not, however, absolve patients from responsibility for any amount that is not covered by the insurer, [5,22] nor does it require that those additional patient-borne costs count toward the beneficiary's deductible or out-of-pocket maximum [3,4]. CMS has proposed standards that would require insurers to
count beneficiaries' cost sharing for essential services from an out-ofnetwork provider in an otherwise in-network setting toward their annual out-of-pocket maximum, but the proposal would not apply to balance billing, or to HMO or EPO plans that do not cover any nonemergency out-of-network services [23]. We found EPO network directories were more likely to include hospital-based specialists, and some evidence of increasing hospital-based specialist inclusion with increasing plan metal level. Knowing this, informed beneficiaries might be inspired to pay higher premiums for plans with broader networks, but broader networks and higher-level plans do not guarantee inclusion of hospital-based physicians. In our data, only 66.7% of EPO network plan directories and 55.2% of Gold plan directories included all four hospital-based specialists. Given the complexity of evaluating and selecting an insurance plan, many buyers on the marketplace exchanges simply choose the cheapest available plan [24], and this appears to be true across all plan metal levels. Even among purchasers of gold and platinum tier plans, approximately 78% of consumers choose narrow-network plans [25]. Individuals insured through their employer or other group plans have little–if any–choice regarding network breadth. For patients, there is little transparency about incomplete network participation, inconsistency in when and how physicians disclose their out-of-network status and its implications on patient-borne costs, and no clear process for resolving disputes about unexpected charges resulting from unintentional out-of-network care 10. This requires policy solutions that protect patients without unfairly eroding the negotiating position of hospital-based physicians, while enabling insurers to contain costs. Some potential solutions are detailed in Table 3. These loosely fit into five themes [1]: new or additional regulations regarding network adequacy [2]; improved beneficiary education [3]; transparency regarding network participation [4]; financial protections for patients; and [5] mediation. The current efforts to revise or replace the ACA offer an opportunity for policy solutions addressing network adequacy across all health insurance products. 4.1. Limitations We studied hospital-based specialists' inclusion in insurance plan network directories, which might not fully represent hospital-based specialists' actual participation in networks [26]. Indeed, some network directories completely omit hospital-based specialists: one recent analysis found 22% of directories for marketplace insurance plans lacked any emergency physicians [27]. The online directories are sometimes difficult to navigate and that too might have affected our ability to identify
Please cite this article as: Brown LH, et al, The risk of unintentional out-of-network encounters with hospital-based physicians at in-network hospitals, American Journal of Emergency Medicine (2017), http://dx.doi.org/10.1016/j.ajem.2017.03.033
L.H. Brown et al. / American Journal of Emergency Medicine xxx (2017) xxx–xxx Table 3 Potential policy solutions. Regulatory
Education
Transparency
Policy makers should more fully define network adequacy, and specifically address inclusion of (or reimbursement for) hospital-based physicians [3,5]. Plan and network marketing materials should be required to include some measure of network breadth and clearly disclose non-inclusion of hospital-based specialists at in-network hospitals [4]. Policy makers, regulators and insurers should provide outreach education to beneficiaries that specifically addresses the issue of unintentional use of out-of-network hospital-based specialists at in-network hospitals [21]. Insurers should include participating hospital-based physicians (or physician groups) in their network provider directories. Hospitals and hospital-based physicians should develop mechanisms to inform patients about their network status. This requires that hospital-based physicians know—or be quickly able to determine—their own network status for various insurance plans [3,5].
Patient Protections
Hospitals and hospital based-physicians should develop mechanisms to inform patients about the costs (or approximate costs) of out-of-network care that they provide before that care is provided [5]. States that provide protections for patients should align the protections for patients in HMO, PPO, EPO and other networks [5,21]. The patient burden for unintentional out-of-network care at in-network hospitals should be no more than their share of the costs for in-network care for the same services [3,5,21].
Mediation
Patient-borne costs for out-of-network care received from hospital-based physicians at in-network hospitals should be counted toward their annual deductible and out-of-pocket maximum [3,5]. Disputes about reimbursement for unintentional out-of-network care should be mediated between insurers and providers, not patients [21].
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network directory—or vice-versa. Also, searching for only the residency director by name likely reduced our ability to identify hospital-based physicians at some hospitals as in-network. For comparison, however, we were able to identify 86.5% of surgery and 89.6% of family practice residency directors at these same teaching hospitals as in-network using the same single-name search methodology. We did search for variations of names, but we could not search for every possible variation. Finally, we did not include hospitalists or neonatologists in our study, although they too are hospital-based specialists who might not be included in the same networks as their parent teaching hospitals [5]. 5. Conclusion The most optimistic interpretation of these data is that patients insured through the ACA exchange insurance plans could find it difficult to identify in-network teaching hospitals where all of the hospitalbased specialists are also in-network. The pessimistic interpretation is that hospital-based specialists frequently are not included in the directories for the insurance networks in which their parent teaching hospitals participate. In either case, these data establish that patients seeking care at in-network academic medical centers could be at significant risk for unintentional out-of-network physician encounters, and that risk is roughly equal across the specialties of emergency medicine, anesthesiology, pathology and radiology. Further research is needed to explore this issue in off-exchange insurance plans and at non-academic hospitals, and to determine the most effective policy solutions for addressing the problem. Acknowledgements The authors have no conflicts of interest with regards to the content of this manuscript. This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors. References
in-network hospital-based physicians, but that would be equally true for all four of the specialties we studied—and for patients attempting to identify in-network physicians. CMS does not provide subscriber data that would allow us to weight our analysis by market penetration, and some of the plans included in our analysis could have relatively few subscribers. However, a post-hoc analysis including only those plans offered by large nationwide insurers (Aetna; Blue Cross/Blue Shield companies; Humana; Kaiser, United Healthcare) produced results only slightly better than those of our primary analysis (emergency medicine: 53.5%; anesthesiology: 52.3%; pathology: 47.7%; radiology: 62.9%; all four specialties: 51.7%). We studied teaching hospitals because for the convenience of data availability, but also because they are more likely to be large tertiary care facilities with specialty services, they are typically perceived as centers that provide exemplary care, and they often serve as the “safety net” in the communities they serve. These data might not be generalizable to non-academic settings. Narrow networks are less likely than broad networks to include academic medical centers [28], the financial incentives for network participation might not be the same for academic versus private practice groups, and reimbursement levels impact academic groups differently than private practice groups [29,30]. Whether those factors result in greater or lesser network participation by hospital-based physicians at non-teaching hospitals will require further research; one could construct a theoretical argument for either effect. We used inclusion of the residency director or the academic practice group in the insurance plans' network directories as our measure of network inclusion of hospital-based physicians. If there had been a recent change in residency director or practice group name, it is possible that the ACGME or CMS data updated more quickly than the insurers'
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Please cite this article as: Brown LH, et al, The risk of unintentional out-of-network encounters with hospital-based physicians at in-network hospitals, American Journal of Emergency Medicine (2017), http://dx.doi.org/10.1016/j.ajem.2017.03.033