Quantifying Balance Billing for Out-of-Network Behavioral Health Care in Employer-Sponsored Insurance

Objective: The study estimated balance billing for out-of -network behavioral health claims and described subscriber characteristics associated with higher billing. Methods: Claims data (2011-2014) from a national managed behavioral health organization's employer-sponsored in-surance (N=196,03 4 family-years with out-of-network behavioral health claims) were used to calculate inflation -adjusted annual balance billing-the submitted amount (charged by provider) minus the allowed amount (insurer agreed to pay plus patient cost-sharing) and any discounts offered by the provider. Among family-years with complete sociodemographic data (N=68,659), regressions modeled balance billing as a function of plan and provider supply, subscriber and family-year, and employer characteristics. A two-part model accounted for family-years without balance billing.Results: Among the 50% of family-years with balance billing, mean +/- SD balance billing was $861 +/-$3,500 (median, $175; 90th percentile, $1,684). Adjusted analysis found balance billing was higher ($523 higher, 95% confidence interval [CI]=$340, $705) for carve-out versus carve-in plans and for health maintenance organization (HMO) enrollees versus non-HMO enrollees ($156, 95% CI=$75, $237); for sub-scribers with a bachelor's degree, compared with an asso-ciate's degree or with a high school diploma or lower (between $172 [95% CI=$228, $116] and $224 [95% CI=$284, $163] higher, respectively); and for subscribers ages 45-54, compared with those ages 35-44 and 18-24 (between $57 [95% CI=$103, $10] and $290 [95% CI=$398, $183] higher, respectively). Balance billing was lower in states with more in-network providers per capita (-$8, 95% CI=-$10, -$5).Conclusions: Balance billing for out-of-network behavioral health claims may be burdensome. Expanded behavioral health networks may improve access. Psychiatric Services 2022; 73:1019-1026; doi: 10.1176/appi.ps.202100157