$25,175 for a single stitch? Why plastic surgeons drive so many 'surprise' medical bills.

When patients receive ED care from plastic surgeons, they sometimes leave the hospital with a massive "surprise" bill—in part because so many plastic surgeons operate outside of insurance networks, Michelle Andrews writes for Kaiser Health News.

Map: The states where patients are most likely to receive a 'surprise' medical bill

How two families found themselves facing unexpectedly high ED bills

Meghan Candee, a pediatric neurologist in Salt Lake City, was visiting family in New York when her four-year-old daughter fell and hit a wooden bench, leaving a small cut underneath her eyebrow. Candee took her daughter to the ED, where she opted for a plastic surgeon to place a single stitch into her daughter's cut with no sedation, Andrews writes.

Candee paid a $100 copayment for the ED visit and removed the stitch herself five days later. But she was later stunned to discover that the out-of-network plastic surgeon had charged $25,175 for the care.

Even though her insurer covered the bill, Candee said she was "furious" at the charge. "This is why people have issues with physicians," she said, "and they think most of us are out there trying to get money."

Candee isn't alone in facing huge bills for emergency care from a plastic surgeon. When Bob Ensor, a 65-year-old New Jersey man, was struck in the face by a boom on a sailboat, he rushed to the ED, Andrews writes. X-rays revealed he had a broken nose and several broken bones in his left eye socket.

The ED physician called a plastic surgeon, who scheduled Ensor to have surgery the next day. Shortly before the surgery, the plastic surgeon introduced Ensor to another plastic surgeon who would be assisting in the surgery, Andrews writes.

During a 90-minute procedure, the physicians successfully realigned Ensor's facial bones—and six weeks later, he received a bill for $71,729 from the assistant plastic surgeon, followed by a $95,885 bill from the first plastic surgeon. Both surgeons, it turned out, were outside of his insurer's network.

"The hospital knew these doctors were out-of-network and didn't bother to tell us," Ensor's wife, Linda, said. "We were panicked."

In the end, the insurer for the Ensors' sailing club wound up covering the bill.

Why plastic surgeons so often bill out-of-network

Out-of-network bills are especially common for emergency plastic surgery, Andrews writes. Researchers at Johns Hopkins Bloomberg School of Public Health separately found that, among hospital admissions in 2016, plastic and maxillofacial surgeons billed out-of-network 23% of the time, more than any other specialists.

Similarly, data from a New York state program arbitrating surprise medical bills found that emergency care involving out-of-network plastic surgeons was the most common type of bill reviewed, with 543 bills reviewed, compared to 335 for emergency physician care and 263 for orthopedists, Andrews writes.

According to Andrews, plastic surgeons are less likely to participate in health plans because their practices typically focus on elective cosmetic procedures that patients typically pay for on their own, Andrews writes. And unlike general surgeons, who may opt to participate in health plans to remain in good standing with hospitals, plastic surgeons generally operate at outpatient centers.

Gregory Greco, the board vice president for health policy and advocacy of the American Society of Plastic Surgeons, said, "Fortunately for some plastic surgeons with alternative revenue streams, they don’t need to participate with insurance companies."

Lawmakers target out-of-network bills

According to Andrew Kleinman, a plastic surgeon in New York City and former president of the Medical Society of the State of New York, a surprise billing law introduced in New York has encouraged plastic surgeons to lower their fees for out-of-network bills.

The program utilizes what is called "baseball arbitration," in which the insurer and provider both submit a proposed charge for the procedure, and an arbitrator picks one, Andrews writes.

"Baseball arbitration gives the physician an incentive not to bill an outrageous rate because [if they do] they're going to lose," Kleinman said. If a provider charges $20,000 while an insurer offers $500, "the insurer will win every time," he said.

It's also important for patients to recognize that a plastic surgeon's expertise may not be required to treat many injuries, according to William Jaquis, president-elect of the American College of Emergency Physicians. "It's not uncommon for a family to say they would like a plastic surgeon," he said. "But in the vast majority of cases, a well-trained emergency physician can do most of the repairs" (Andrews, Kaiser Health News, 5/6).

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