Health care providers in the South may be hiking up prices more for emergency care and critical care than for colon cancer detection and radiation therapy.

Analysts at America's Health Insurance Plans (AHIP) have raised that possibility with state-by-state health care cost data they have published in a look at gaps between what providers bill privately insured out-of-network (OON) patients and what they bill Medicare enrollees.

AHIP created the cost report to draw policymakers' attention to differences between what similar providers in different parts of the United States charge for the same procedure, and the differences between what patients with different types of health coverage pay for the same procedure.

The AHIP analysts calculated the typical gap between what the providers in a state charge OON patients for seven procedures and what they charge Medicare patients for the same procedures.

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For each procedure, the analysts used the OON-to-Medicare billing ratios to break states into three categories:

states with relatively small gaps between the OON bills and the Medicare bills
states with medium-big gaps
states with large gaps

For a high-intensity emergency department visit, for example, a state was in the low-biller category if its providers charged OON patients less than 422 percent of what they charged Medicare enrollees.

A state ranked in the high-biller category if its providers' OON-to-Medicare billing ratio was over 516 percent.

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For MRIs of the brain, the OON-to-Medicare ratio cut-off for making it into the low-biller category was 644 percent. In the states in the high-biller category, the providers' OON-to-Medicare ratio was over 806 percent.

For three of the procedures--high-severity emergency department visits, the first hour of critical care, and MRIs of the brain, with or without dye--most Southern states were in the high-biller category.

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Southern state providers were about as likely as providers in other states to bill high for laparoscopic cholecystectomies and for upper gastrointestinal endoscopy with biopsies.

But the Southern state providers were in the low-biller category for colonoscopies with biopsies and for intensity modulated radiation therapy treatment for cancer.

Providers in Oklahoma and South Carolina have been high billers for emergency care but low billers for radiation therapy.

In Louisiana, for example, providers were in the high-biller category for emergency care and critical care, but they were in the low-biller category for radiation therapy.

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AHIP analysts note that they used billed amounts for their analysis. They did not have access to detailed information about discounted provider network rates or other rate discount arrangements.

Instant Insights /

Are health care providers setting costs based on patient coverage?

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