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One way that health plans attempt to control costs is by creating networks of clinicians and health care facilities with whom they negotiate discounted rates on behalf of their enrollees. This is known as selective contracting. Enrollees have a financial incentive to use in-network clinicians and health care facilities. They face higher cost-sharing with their health plan and a financial risk of additional charges (balanced billing) submitted to them directly by clinicians when they use services that are out of network.
But individuals do not always have a choice of an in-network facility, such as when an ambulance transports patients to the closest hospital regardless of whether it is in network. Further complicating the situation is that individuals may mistakenly believe that all physicians at in-network facilities are in-network clinicians, when in fact many—particularly those who furnish radiology, pathology, anesthesiology, and emergency services—are not.
Bindman A. Curbing Surprise Medical Bills Can Be a Window Into Cost Control. JAMA. 2018;320(20):2065–2066. doi:10.1001/jama.2018.17418
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