Patients with cancer can get a cruel surprise when they receive unexpected bills for costly “out-of-network” services provided in their ostensibly “in-network” hospital.

Add in high monthly insurance premiums and deductibles, substantial copays, and the euphemistically named “coinsurance,” and the unsuspecting patient can get a very nasty surprise indeed, says a team of physicians and healthcare analysts.

In a study published online February 17 in The American Journal of Managed Care, they found that wide variation in markups on outpatient oncology services in the United States can impose severe financial hardships on many patients.

“What we found in the marketplace is that over one quarter of the medical centers that provide cancer services are charging more than 5.1 times the Medicare allowable amount, and in some cases the centers are charging more than 15 times the Medicare allowable amount,” said lead author, Martin A. Makary, MD, MPH, a cancer surgeon at Johns Hopkins Hospital in Baltimore, Maryland.

“Either this is a game that’s gone awry, or it’s just outright price gouging in the marketplace, and I think it’s fair to ask, in a vulnerable time in someone’s life, is it fair or reasonable to inflate a bill that much without their prior consent?” he added.

In their study, the researchers reviewed Medicare Part B physician reimbursement data from 2014 and found wide swings in markup of services by hospitals in many different oncologic specialties, including radiology, hematology/oncology, medical oncology, pathology, and radiation oncology.

Medical oncology services provided in for-profit cancer centers, and radiology and pathology services provided in “prestige” institutions, were associated with higher markups, they found.

And although insurers can haggle with hospitals to agree on reimbursement levels below prices on the hospital’s “chargemaster” — a comprehensive list of billable goods and services — individual patients often get stuck paying full retail prices.

“On a moral level, we believe that it is unethical for a nonprofit medical center to put a patient with cancer into household bankruptcy because they cannot pay a bill inflated above what Medicare would pay for the identical service,” they write.

Makary said in an interview with Medscape Medical News that “the poor bystanders in this system are the out-of-network patients — a growing group in the United States — the uninsured, and those who as a part of their religious faith pay their bills in full, such as the Amish and other faith-based communities.”….