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February 13, 2020

You're at an in-network facility with an in-network surgeon. What are your odds of an out-of-network bill?

Daily Briefing

    About one in five patients who underwent elective surgeries with an in-network surgeon at an in-network facility might have received a medical bill with out-of-network charges, according to a study published Tuesday in JAMA that experts say highlights how difficult it can be for patients to avoid surprise charges.

    The surprise billing legislative landscape: What can we learn from states' experiences?

    Study details

    For the study, researchers from the University of Michigan (UM) and Harvard Medical School analyzed claims data from a private insurer on 347,356 patients who received an elective procedure with an in-network surgeon at an in-network facility between Jan. 1, 2012, and Sept. 30, 2017. The researchers focused on seven common elective surgeries: arthroscopic meniscal repair, breast lumpectomy, colectomy, coronary artery bypass graft surgery, hysterectomy, laparoscopic cholecystectomy, and total knee replacement.

    The researchers did not have access to the total out-of-network charges patients received. However, they estimated the out-of-network costs that might have been passed on to patients by determining the difference between the total out-of-network charges billed to the insurer for each surgery and the amount the insurer typically would pay for the care.


    Overall, the researchers found that 20% of the care episodes examined resulted in out-of-network charges. The average out-of-network charge patients might have received totaled $2,011.

    According to the researchers, there were a number factors that affected a patient's likelihood of receiving out-of-network charges. For instance, the researchers found that out-of-network charges often occurred because members of a patient's surgical team, such as anesthesiologists and surgical assistants, were not in their health plan's network.

    The researchers also found that patients enrolled in Affordable Care Act exchange plans were more at risk of receiving out-of-network charges than other privately insured patients because the exchange plans typically had comparatively narrower provider networks. The researchers said patients with surgical complications also were at a higher risk of receiving out-of-network charges when compared with patients who did not experience complications.

    Additionally, the researchers found that a patient's chances of receiving out-of-network charges varied widely by state. The incidence rate of out-of-network charges ranged from 3% in Nebraska to 46% in Alaska.

    Further, the researchers found eight states—California, Connecticut, Florida, Illinois, Maryland, Massachusetts, Mississippi, and New York—with laws in place to prevent unexpected out-of-network billing had rates of out-of-network charges above the national median for elective surgeries with in-network surgeons at in-network facilities. "This suggests … that these states may have been responding to endemic surprise billing problems, and that these policies may not have been completely effective," the researchers wrote.

    Study shows it can be difficult for patients to avoid surprise out-of-network bills

    The researchers said their findings run counter to previous research that suggested EDs "staffed by private equity-backed medical groups [were] the primary source of out-of-network billing."

    Karan Chhabra, the study's lead author, in a release said the study shows that "[e]ven if patients do their homework before they have elective surgery … they can be at risk of receiving large bills they never expected, from providers they never met or even knew about."

    Justin Dimick, a surgery chair at UM and senior author of the study, explained, "Even if a patient takes care to choose an in-network surgeon, and an in-network hospital or surgery center, they have little to no control over the rest of the team involved in their care, and whether they take part in their insurance plan."

    And Chhabra said it's possible clinicians sometimes are unaware of network issues that could result in out-of-network charges for patients. "[Doctors] don't always talk about which insurance everyone accepts," he said.

    Further, Chhabra noted that clinicians might not be able to control which providers are involved in a patients' care team. For example, he explained that while surgeons often can pick which surgical assistants they work with, they often cannot choose which anesthesiologists are involved in their procedures.

    But Erin Duffy, a research fellow at University of Southern California's Center for Health Policy and Economics, cautioned that the study doesn't reflect the actual rate of so-called "surprise" out-of-network bills patients received because of the method the researchers used to estimate out-of-network charges. In addition, Duffy said the findings might not be representative of all providers because it relied on data from only one commercial insurer (Cohrs, "Transformation Hub," Modern Healthcare, 2/11; Lam, USA Today, 2/11; Renken, "Shots," NPR, 2/11; Khazan, The Atlantic, 2/11; University of Michigan release, 2/11).

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