The Problem

Surprise medical bills – also known as “balance billing” – is one of the most pressing affordability concerns facing American consumers and families. Under current law and practice, most states allow a doctor to bill a patient for any balance that may be outstanding after the health insurance provider pays its designated cost. But those charges become truly problematic for patients when out-of-network providers—who are not bound by contractual, in-network rate agreements with an insurance provider—bill patients for the entire remaining balance.

Surprise billing can break the bank for hardworking Americans with bills totaling thousands of dollars – often in cases where patients had no choice of a provider. For example, every year, Americans make about 137 million visits to emergency rooms in the United States. At least 1 in 5 patients who have health insurance will receive a surprise bill from a provider or specialist who treated them.  

Importantly, not all doctors or local hospitals are the culprits behind surprise bills. The real issue is when clinical specialists or providers choose not to participate in health insurance providers’ networks – or if they do not meet the standards for inclusion in a network – and can then demand a blank check from patients for their services.

These specialty providers are likely to charge substantially more than their peers in other specialties, not accept private insurance, and are not actively chosen by patients. Studies have found that surprise medical bills are most likely to come from emergency medicine physicians, anesthesiologists, radiologists, and pathologists. For example, one study found that:

  • Anesthesiologists charge, on average, 5.8 times the Medicare reimbursement rate;
  • Radiologists charge, on average, 4.5 times the Medicare rate;
  • Emergency medicine physicians and pathologists charge, on average, 4 times the Medicare rate.

Additional Resources