Among Americans who underwent elective surgery within their insurance network, one in five received a "surprise" out-of-network medical bill afterward, researchers said.
Of 347,000 patients whose operations were performed by surgeons and in facilities that were in-network, 20.5% nevertheless had charges from an out-of-network provider, reported Karan Chhabra, MD, of the University of Michigan in Ann Arbor, and colleagues in JAMA.
The estimated "balance bills" averaged $2,011 (a figure that comes with considerable uncertainty, given the study's methods).
Providers most commonly associated with out-of-network charges were surgical assistants and anesthesiologists, each of which were involved in 37% of cases. About 22% included bills from pathologists.
In an interview with MedPage Today, Chhabra said that it was surprising to see that patients still received out-of-network medical bills after they chose to have procedures within their insurance network. "One in five patients could be on the hook for $2,000, in addition to what they are already paying for their care," he said.
Chhabra also noted that out-of-network bills for clinicians such as surgical assistants and anesthesiologists might be within a primary surgeon's control, which is a cause for concern. "We don't know how often this happens, but we've heard stories that this might be an intentional billing tactic," Chhabra said.
In an accompanying commentary, JAMA Associate Editor Karen E. Joynt Maddox, MD, MPH, and Deputy Editor Edward Livingston, MD, wrote that surprise billing practices "are particularly pernicious because patients usually have no knowledge that they will occur, and no way to avoid them." Maddox and Livingston called on surgeons to ensure they do not involve out-of-network clinicians in a patient's care, as well as policymakers to protect patients from unanticipated and "potentially devastating" medical bills.
Surprise billing occurs when a patient treated at an in-network facility receives unexpected out-of-network charges, often for care provided by out-of-network clinicians. An analysis by the Kaiser Family Foundation found that two-thirds of U.S. adults are worried about their ability to pay for unexpected medical bills, prompting proposals in the House and the Senate to prohibit surprise bills.
Previous studies have looked into the prevalence of surprise bills in emergency care, Chhabra and colleagues noted, however there is little research for elected procedures. These researchers wanted to assess how many patients that underwent common surgical procedures, in which they were able to choose an in-network surgeon and facility, still received out-of-network bills.
Study Details
Chhabra and colleagues evaluated the proportion of episodes that had out-of-network bills and the estimated potential balance bill associated with each procedure. They analyzed Clinformatics claims data from a single, private insurer for seven different surgical procedures that occurred from January 2012 to September 2017.
Surgical procedures included arthroscopic meniscal repair, laparoscopic cholecystectomy, hysterectomy, total knee replacement, breast lumpectomy, colectomy, and coronary artery bypass graft surgery. All surgeries were performed by an in-network surgeon at an in-network medical facility.
Notably, the researchers' data did not indicate what patients' insurers paid for out-of-network care, and thus Chhabra and colleagues could only make educated guesses about the out-of-network bills patients received. "The payments in the data set were adjusted to the typical in-network price for each service across the United States," they explained. "Thus, this study's calculations of potential balance bills reflected an estimate of the dollar amount patients could be balance-billed but not the actual amount that was balance-billed."
Study participants were age 48 on average, and around two-thirds were women. Most of the patients analyzed underwent arthroscopic meniscal repair (34%), followed by laparoscopic cholecystectomy (24%) and hysterectomy (19%).
Of 347,000 episodes, one in five received an out-of-network bill. While the average potential balance bill was $2,000, bills ranged by procedure from $1,255 for a laparoscopic cholecystectomy, to $3,499 for coronary artery bypass graft surgery.
Surgical assistants and anesthesiologists were both associated with out-of-network claims in 37% of cases, however the estimated balance bill was higher for surgical assistants. The average estimated balance bill for out-of-network anesthesiologists was $1,219, compared to an average of $3,633 for a surgical assistant. Most surgical assistants were physician assistants, but registered nurses, certified surgical assistants, or other surgeons were also included in this category.
In a multivariable analysis, researchers found that patients with a self-insured plan had a significantly lower risk of receiving an out-of-network bill than patients with fully-insured plans (19% vs 22%, respectively). Patients with exchange plans had a 6% higher risk (95% CI, 3.9% to 8.9%) of getting hit with a surprise bill than those with nonexchange plans. It was concerning, Chhabra said, to see higher risk surprise medical bills in the more vulnerable populations insured by exchange plans.
Jack Hoadley, PhD, of the Health Policy Institute of Georgetown University's McCourt School of Public Policy, said that this study is consistent with previous findings. However, Hoadley, who was not involved in this study, also said this information is clarifying for both patients and policymakers. "It helps you think about where your vulnerabilities are as a patient, not that there's anything you can do about it," he told MedPage Today. Hoadley thinks this study provides clear evidence that a policy solution is necessary.
Chhabra and colleagues noted that their study is limited by its use of data from one, single insurance payer, and that some individuals showing out-of-network balances may not actually have been billed or may have agreed to the out-of-network care.
One co-author reported that he is a cofounder of ArborMetrix, a company that produces software that profiles hospital quality. No other study authors reported conflicts of interest. Joynt Maddox received grant funding from the National Institutes of Health and the Commonwealth Fund, and reported receiving compensation for previous contract work from the Department of Health and Human Services.
This study received funding from the University of Michigan Institute for Healthcare Policy and Innovation Policy Sprints Program. Additional funding was received from the National Institutes of Health.
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February 11, 2020 at 11:00PM
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One-Fifth of In-Network Surgeries Come With Surprise Bills - MedPage Today
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