By NextBestFitEliminate out-of-network status
With one payer or universal all-payer rates, there is no out-of-network.
Out-of-network ends with one payer.
Review ledgerHow this path connects
This path
Eliminate out-of-network status
Requires:
Every licensed provider is in-networkNarrow networks and out-of-network surprisesChosenConcrete changes if chosen
What would actually have to change in law, agencies, payment rules, or systems.
- Eliminate network status for covered services
- Ban balance billing by any provider that bills the program
Effects
Each effect has its own page: the evidence, the case that it is or isn't a real cost, and whom it affects.
What it fixes
- Surprise billing and a runaway arbitration system
A single payer or universal all-payer rates removes out-of-network billing and ends surprise bills entirely. It also removes the federal dispute-resolution system and its cost.
- About $1 trillion a year in administrative cost
Removing out-of-network billing eliminates the federal dispute-resolution system and its cost.
What it creates or worsens
- Depends on other changes to work
Removing out-of-network billing requires all providers to accept the payer or uniform rate.
- Providers leave, retire, or go cash-only if pay drops
Providers opting out can still charge patients directly.
3 paths soften this
Phase rate changes in over several yearsProviders leave, retire, or go cash-only if pay dropsChosenStrict opt-out rules for cash-only practiceProviders leave, retire, or go cash-only if pay dropsChosenLower costs for clinicians, not only payProviders leave, retire, or go cash-only if pay dropsChosen
Who's affected
Who gains
- People with ongoing or specialist care needs
- Surprise billing and a runaway arbitration system: Ambulance rides and out-of-network specialists send bills patients didn't choose.
- People with employer coverage
- Surprise billing and a runaway arbitration system: Premiums fund the higher arbitration awards.
- About $1 trillion a year in administrative cost: Premiums pay for the administration.
- Doctors, nurses, and other clinicians
- About $1 trillion a year in administrative cost: Time goes to billing and insurer rules instead of patients.
- Taxpayers and public budgets
- About $1 trillion a year in administrative cost: Public programs pay for it too.
- Cash-pay and private care practices
- Providers leave, retire, or go cash-only if pay drops: Payment cuts can shift providers toward cash-only care.
Who loses
- Hospitals and specialist groups with high private prices
- Surprise billing and a runaway arbitration system: Private-equity-backed emergency, anesthesia, and radiology groups win high awards.
- Health insurers, brokers, and their shareholders
- About $1 trillion a year in administrative cost: Insurers, billing firms, and clearinghouses earn from the complexity.
- Insurance and billing workers
- About $1 trillion a year in administrative cost: Their jobs exist because of the complexity.
- Health administration and software vendors
- Depends on other changes to work: Removing out-of-network billing requires all providers to accept the payer or uniform rate.
- Private equity firms and investors
- Depends on other changes to work: Removing out-of-network billing requires all providers to accept the payer or uniform rate.
- People with ongoing or specialist care needs
- Providers leave, retire, or go cash-only if pay drops: Provider retirements, opt-outs, and closures reduce access in affected specialties and regions.
- Residents of areas with too few health professionals
- Providers leave, retire, or go cash-only if pay drops: Provider retirements, opt-outs, and closures reduce access in affected specialties and regions.
Where it has been tried
- Canada: No networks for publicly covered services.
- Taiwan: At the end of 2023, Taiwan's national insurer contracted with 23,085 hospitals and clinics, representing 91.6% of medical institutions nationwide.