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Analysis

Surprise Billing Prevalent in Elective Surgeries

By John Commins  
   February 11, 2020

A study found that 20.5% of elective surgeries came with an out-of-network bill with an average charge of $2,011.

About one-in-five patients undergoing elective surgeries at in-network hospitals is slapped with an out-of-network bill, new research shows.

A study published this week in JAMA looked at one large commercial insurer's claims data on nearly 350,000 adult beneficiaries who underwent elective surgeries for common procedures with in-network surgeons and hospitals between 2012 and 2017.

The study found that 20.5% of the cases came with an out-of-network bill, averaging $2,011, with most of the out-of-network billing attributed to surgical assistants or anesthesiologists.

Beneficiaries in health insurance exchange plans had a significantly higher risk of out-of-network bills (27%) when compared to beneficiaries in non-exchange plans (20%).

Of the 83,021 surgeries performed at ambulatory surgery centers with in-network primary surgeons, 6.7% included an out-of-network facility bill and 17.2% included an out-of-network professional bill.

Surgical complications were associated with a significantly higher risk of out-of-network bills (28%), compared with episodes with no complications (20%).

For the most part, the public discussion around out-of-network billing has focused on emergency care. A study published in November in JAMA Internal Medicine found that the percentage of emergency department visits that included a surprise bill grew from 32% in 2010 to 43% in 2016.

in an editorial accompanying the study, Melinda Buntin, chair of the Department of Health Policy at Vanderbilt University School of Medicine, said the findings "add to the widespread sense that surprise billing is prevalent and unfair and illustrate that it is not isolated to a limited set of private equity–backed medical groups."

"What they unfortunately cannot shed light on is which of the policy solutions on the table will best solve the problem," she said.

The study comes as Congress debates out-of-network bills that can leave insured patients on the hook for financially crippling medical debts. Buntin said Congress should take note of these latest findings.

"Hopefully, a compromise will be reached between those in Congress who favor setting a benchmark rate for compensating out-of-network providers in these situations and those who favor arbitration between insurers and out-of-network providers," Buntin said.

"What is not the subject of debate among lawmakers is that patients should not be left paying these bills in full—and yet that is exactly what will happen if Congress is not able to agree on a path forward."

“The data add to the widespread sense that surprise billing is prevalent and unfair and illustrate that it is not isolated to a limited set of private equity–backed medical groups.”

John Commins is a content specialist and online news editor for HealthLeaders, a Simplify Compliance brand.


KEY TAKEAWAYS

Most of the out-of-network billing was attributed to surgical assistants or anesthesiologists.

Surgical complications were associated with a significantly higher risk of out-of-network bills.


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