A substantial number of out-of-network claims are associated with patients who have fewer specialists available within their network. That's particularly true when patients seek treatment from mental health and substance abuse providers.
Seeing out-of-network providers can cause patients to pay significantly more in out-of-pocket costs, but some patients are willing to bear this cost under certain conditions. Even aside from controversial "surprise billing" practices, patients may intentionally seek out providers that aren't in their network due to familiarity, reputation or convenience, according to a recent brief from the Kaiser Family Foundation (KFF).
But patients who sought outpatient mental health services were significantly more likely than other patients to have an out-of-network claim, KFF found in its analysis of people with large employer coverage. Specifically, patients with an outpatient psychotherapy or therapeutic psychiatric claim submitted out-of-network claims at more than triple the rate of patients overall.
"The high incidence of out-of-network claims for mental health and substance abuse services stands out for both inpatient admissions and outpatient service days," the authors wrote. "These high rates raise questions about the availability of services within plan networks, and perhaps of the quality of the network providers. In some cases, services may be urgent and patients may not have in-network options available."
Much of the attention and policy fixes aimed at out-of-network billing issues have been rightfully focused on so-called surprise billing: the inadvertent use of out-of-network providers during the course of inpatient treatment. And Kaiser's analysis displayed many of the causes of that practice that force patients to pay significant sums of money.
Patients with an emergency room claim were almost twice as likely to submit an out-of-network claim as patients without an emergency room claim, Kaiser found. And anesthesia and pathology claims—providers that patients rarely select directly—were more likely to be out of network as well.
But even among inpatient admissions, patients seeking mental health services are the most likely to end up submitting out-of-network claims.
This indicates that patients seeking mental health or substance abuse treatment services can have problems finding in-network facilities and providers.
As Kaiser noted, this narrow network problem hasn't gotten the same attention as the surprise billing issue. And policy fixes that address surprise billing may not solve the problem of access to in-network mental health providers.
"While policymaking has primarily focused on surprise situations—where enrollees receive an out-of-network claim as part of receiving services in an in-network facility—the very large share of out-of-network claims for mental health and substance abuse services, even when no facility claim is involved, suggests that other types of policy interventions may need to be considered," the brief concluded.