Beyond oncology, cancer patients often interact with specialists that have high rates of out-of-network billing, such as anesthesiologists, pathologists, radiologists, and assistant surgeons. “All of these specialties are generally specialties that the patients don’t choose,” said Nathan Shekita, an MBA/MPH candidate at Yale University in New Haven, Connecticut, in an interview with Cancer Therapy Advisor. These specialists often work at facilities that are otherwise in network, so patients have no reason to suspect they’ll be treated by an out-of-network provider. In a recent Health Affairs study, Shekita and coauthors reported that at hospitals in 1 insurer’s network, claims from the aforementioned 4 specialties were out of network approximately 5% to 12% of the time.5

Emergency room physicians are also often employed by out-of-network companies. Patients undergoing cancer treatment may find themselves experiencing side effects, such as nausea, that require urgent attention, Dr Polsky noted. In the middle of the night, patients may choose the closest ER, rather than take the time to research where physicians are most likely to accept their insurance plan.

While certain specialties do have higher rates of out-of-network billing, most physicians prefer to be in network, said Zeke Silva III, MD, chair of the American College of Radiology’s Commission on Economics. Being in a network means access to that group of patients. “But you want to be in network for rates that are reasonable,” he told Cancer Therapy Advisor. If price negotiations between provider and insurer falter, the doctor or practice will end up outside the network.

“It’s just important to recognize, when you’re sending your patients to see other doctors, that you make that extra effort to see if they’re in network,” said Dr Polsky. “You can’t just assume that because they’re in your system, they’re in your network.”

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He suggested that doctors might informally crowdsource the issue, tracking and sharing when patients receive surprise bills. Cancer physicians might also advise patients about where to seek emergency services, if side effects or other issues are likely.

However, no one wants to compromise treatment over insurance issues. “If there’s a person that can perform the service that my patient needs, that is in network, then I will refer to that person,” Dr McAneny said. “But if a cancer patient needs a specific surgeon, for example, who has expertise in their particular area, it is way more important for me to get the right consultant, the right surgeon — with expertise — than it is to stay in network.”

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Her office does make efforts to ease financial burdens. For example, Dr McAneny’s practice employs 2 pharmacy technicians solely devoted to obtaining medication preauthorization from insurers. And the group tries to avoid patients needing the ER by offering same-day appointments, and being accessible by phone at all times, day or night. The practice also has an in-house foundation that helps patients with basic expenses like groceries or rent.

Physicians concerned about costs for patients may also wish to advocate, via local or national medical associations, for transparent billing that holds patients harmless. Dr Silva pointed to New York’s law as a model, which requires independent arbitration of disputed bills between physician and insurer.

Dr Silva also noted that when insurers have large, robust networks, going out of network becomes less common and problematic.

“We want patients to be in the mindset of healing … not worrying about, ‘is this doc in network?'” said Dr Silva. “I think we’ll get there.”


  1. Banegas MP, Guy GP, de Moor JS, et al. For working-age cancer survivors, medical debt and bankruptcy create financial hardships. Health Aff (Millwood). 2016;35(1):54-61.
  2. The American Cancer Society Cancer Action Network (ACS CAN). Survivor views: Surprise billing and prescription cost and coverage — Survey findings summary. Published December 5, 2019. Accessed February 3, 2020.
  3. Board of Governors of the Federal Reserve System. Report on the economic well-being of U.S. households in 2017. Published May 2018. Accessed February 3, 2020.
  4. Yasaitis L, Bekelman JE, Polsky D. Relation between narrow networks and providers of cancer care. J Clin Oncol. 2017;35(27):3131-3135.
  5. Zooper Z, Nguyen H, Shekita N, Morton FS. Out-of-network billing and negotiated payments for hospital-based physicians. Health Aff (Millwood). 2020;39(1):24-32.