School of Public Health, University of Nevada, Reno (Friedman); Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine (Xu, Ettner), and Department of Health Policy and Management, Fielding School of Public Health (Ettner), University of California, Los Angeles, Los Angeles; Optum, San Francisco (Azocar).
Psychiatr Serv. 2022 Sep 1;73(9):1019-1026. doi: 10.1176/appi.ps.202100157. Epub 2022 Mar 23.
The study estimated balance billing for out-of-network behavioral health claims and described subscriber characteristics associated with higher billing.
Claims data (2011-2014) from a national managed behavioral health organization's employer-sponsored insurance (N=196,034 family-years with out-of-network behavioral health claims) were used to calculate inflation-adjusted annual balance billing-the submitted amount (charged by provider) minus the allowed amount (insurer agreed to pay plus patient cost-sharing) and any discounts offered by the provider. Among family-years with complete sociodemographic data (N=68,659), regressions modeled balance billing as a function of plan and provider supply, subscriber and family-year, and employer characteristics. A two-part model accounted for family-years without balance billing.
Among the 50% of family-years with balance billing, mean±SD balance billing was $861±$3,500 (median, $175; 90th percentile, $1,684). Adjusted analysis found balance billing was higher ($523 higher, 95% confidence interval [CI]=$340, $705) for carve-out versus carve-in plans and for health maintenance organization (HMO) enrollees versus non-HMO enrollees ($156, 95% CI=$75, $237); for subscribers with a bachelor's degree, compared with an associate's degree or with a high school diploma or lower (between $172 [95% CI=$228, $116] and $224 [95% CI=$284, $163] higher, respectively); and for subscribers ages 45-54, compared with those ages 35-44 and 18-24 (between $57 [95% CI=$103, $10] and $290 [95% CI=$398, $183] higher, respectively). Balance billing was lower in states with more in-network providers per capita (-$8, 95% CI=-$10, -$5).
Balance billing for out-of-network behavioral health claims may be burdensome. Expanded behavioral health networks may improve access.
本研究估计了网络外行为健康索赔的平衡计费，并描述了与更高计费相关的用户特征。
使用来自一家全国性管理行为健康组织的雇主赞助保险的索赔数据（2011-2014 年，N=196,034 个网络外行为健康索赔的家庭年），计算通货膨胀调整后的年度平衡计费-提交金额（由提供商收取）减去允许金额（保险公司同意支付的金额加上患者自付额）和提供商提供的任何折扣。在具有完整社会人口统计学数据的家庭年中（N=68,659），回归模型将平衡计费作为计划和提供商供应、用户和家庭年以及雇主特征的函数进行建模。两部分模型用于平衡计费为零的家庭年。
在有平衡计费的 50%的家庭年中，平均±SD 平衡计费为$861±$3,500（中位数，$175；第 90 百分位数，$1,684）。调整后的分析发现，与内置计划相比，网络外计划和健康维护组织（HMO）参保人比非 HMO 参保人的平衡计费更高（高出$523，95%置信区间[CI]=$340，$705）；与具有学士学位的用户相比，具有副学士学位或高中学历或更低学历的用户的平衡计费更高（分别高出$172 [95% CI=$228，$116]和$224 [95% CI=$284，$163]）；与 35-44 岁和 18-24 岁的用户相比，45-54 岁的用户的平衡计费更高（分别高出$57 [95% CI=$103，$10]和$290 [95% CI=$398，$183]）。按人均网络内提供商数量划分，平衡计费在网络内提供商数量较多的州较低（$8，95% CI=$10，$5）。
网络外行为健康索赔的平衡计费可能是负担沉重的。扩大行为健康网络可能会改善获得途径。
