Patients with private insurance often have to pay high out-of-pocket fees for advanced imaging -- and they can be held accountable for 100% of the cost if the service is performed out of network, according to a study published online February 21 in the Journal of the American College of Radiology.
The findings suggest that in an era of "shared decision-making," radiologists need to help their patients understand the complete financial picture so they can make the most informed healthcare decisions, wrote the team led by Dr. Andrew Rosenkrantz of NYU Langone Medical Center.
"To more effectively engage patients in shared decision-making and mitigate the hardships of surprise balance billing, radiologists should facilitate transparent communication of advanced imaging costs," the researchers wrote.
Across the U.S. private insurance marketplace, patients often incur high out-of-pocket costs for advanced imaging, particularly when services are performed out of network, they wrote. Because radiologists often don't understand the costs of exams and how those costs translate to their patients, the researchers sought to characterize how much advanced imaging costs for privately insured patients.
Rosenkrantz and colleagues used 2017 data from the Health Insurance Marketplace Benefits and Cost Sharing Public Use File, which is maintained by the U.S. Centers for Medicare and Medicaid Services. The database outlines coverage policies for 18,429 health plans on federally facilitated marketplaces and measures out-of-pocket costs for advanced imaging and other health benefits.
Independent of deductibles, 48% of plans required coinsurance payments (expressed as a percentage fee) for advanced imaging and 9.7% required co-payments (expressed as a flat fee), while 8% required both and 34.3% required neither. For out-of-network services, 91% required coinsurance, 0.1% required co-payments, 1% required both, and 7.4% required neither, the researchers found.
With deductibles, patient coinsurance responsibility for advanced imaging in network was 27.7%, with an average co-payment of $319, while out-of-network responsibility was 47.7%, with an average co-payment of $630. For policies without deductibles, patients' average out-of-network coinsurance responsibility for advanced imaging was 99.9%.
Rosenkrantz and colleagues also found that out-of-network coinsurance percentages tended to be higher in lower-income states, highlighting how variations in a regional plan benefit design can create disproportionate cost-share burdens among vulnerable populations.
To interact more effectively with patients, health systems, and policymakers, radiologists must become more familiar with factors that influence their patients' out-of-pocket expenses for imaging exams, the authors wrote.
"With greater awareness of patients' out-of-pocket cost responsibilities, radiologists may be more judicious in recommending additional or follow-up imaging, knowing that those recommendations frequently translate into high costs borne substantially, and sometimes completely, but their patients," they concluded.