by University
of Michigan FEBRUARY 11, 2020
Key findings from the
study of surprise billing in elective surgery. Credit: University of Michigan
As if
recovering from surgery wasn't hard enough, a new study shows that one in five
operations could result in an unwelcome surprise: a bill for hundreds or
thousands of dollars that the patient didn't know they might owe.
On
average, that potential surprise bill added
up to $2,011, a team from the University of Michigan reports in the new issue
of JAMA. That's on top of the nearly $1,800 the average privately
insured patient would already owe after their insurance company paid for most of the
costs of their operation.
All the
patients in the study chose a surgeon who accepts their insurance, and had one of
seven common, non-emergency operations at an in-network hospital or at an
outpatient surgery center.
But
they still ended up potentially owing large sums to pay other people involved
in their operation or their follow-up care. The average potential surprise bill
ranged from $86 for medical imaging specialists involved in a hysterectomy, to
more than $8,000 for surgical assistants involved in a breast lumpectomy. These
out-of-network bills were significantly more common for patients who had
complications after surgery.
If the
patient had an outpatient procedure with an in-network surgeon, but it took
place at an ambulatory surgery center that was out-of-network, the potential
surprise bill could add up to more than $19,000.
"These
are eye-popping numbers, which most clinicians are likely unaware of, and which
patients can't prepare for," says Karan Chhabra, M.D., M.Sc., the study's
first author and a National Clinician Scholar at the U-M Institute for
Healthcare Policy and Innovation, which funded the study.
The
study looked at the claims that a large insurance company received from
in-network and out-of-network medical providers for more than 347,000
patients under age 65 who had one of the seven operations between 2012 and
2017. Even though all the lead surgeons and the surgery locations were
in-network, 20.5% of the operations led to an out-of-network bill.
The
researchers couldn't see the actual "balance bills" that patients
were told they must pay, which may vary depending on the insurance plan's
provisions. Some insurers may pay part of the bill for out-of-network
providers, while others charge patients for the entire added cost.
For the
study, the researchers tallied all out-of-network charges billed to the insurer
for the care episode related to each operation, and deducted the insurer's
typical payment for that care.
State
and federal implications
The
findings shine a light on the need for federal-level measures to address
surprise billing, says Chhabra, a research fellow in the Department of Surgery
at Michigan Medicine, U-M's academic medical center, and a house officer at
Brigham and Women's Hospital in Boston.
That's
because state-level policies can't regulate what are called self-insured health
insurance plans—the kind of plan that covers most people who get insurance
through their jobs or the job of a family member.
Congressional
committees have worked on legislation to address surprise billing but have
still not agreed on a final legislative fix, though several states have passed
provisions that provide some protection.
Depending
on what state the patient lives in, the risk of getting a surprise bill
differed from the average. In some states, less than 10% of the operations
covered by the insurer led to a surprise bill, while in others more than a
third did. Southern states had the highest proportion of surprise bills.
The
team matters, not just the lead surgeon
"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," says U-M surgery chair Justin Dimick, M.D., M.P.H., senior author
of the new paper. "This study reveals the extent and size of the bills
that these other providers can incur if they're not in-network."
Chhabra
notes that he and his colleagues were especially surprised that 37% of surprise
bills sought payment for "surgical assistants." This is a catch-all
term for other people with hands-on involvement in the operation or in
post-operative care. They include additional surgeons, nurse practitioners or
physician assistants with surgical training, or mid-level providers called
certified surgical assistants or sometimes surgical first assistants.
When
such a person was involved and wasn't part of the insurance network, the
average bill for their services was $3,633.
Surgical
assistants or their employer can bill the insurance company separately for
their services, and seek payment above and beyond the rate that the insurer
might have agreed on with the hospital.
Other
types of physicians also submitted out-of-network bills as part of the care
time. For instance, 37% of operations involved an out-of-network
anesthesiologist, but the potential average surprise bill from them was lower
than for surgical assistants, at around $1,200.
"Even
if patients do their homework before they have elective surgery, this study
shows they can be at risk of receiving large bills they never expected, from
providers they never met or even knew about," says Chhabra.
The
researchers also did a separate analysis of 83,000 operations performed at
ambulatory surgery centers, for patients who had in-network surgeons. In this
group, 17% of patients might have received a surprise bill for an
out-of-network provider on their surgical team—but 6.7% might have received a
bill from the surgery center itself because it was out-of-network.
Implications
for surgeons
He
notes that when all providers are in-network, such as at a large health system
with employed physicians, the patient doesn't necessarily need to know or
choose which pathologist looks at the tissue removed from them, which
radiologist looks at the medical images made of them, or which specialist has
the lead in the intensive care unit where they recover.
But
when some of those providers are out-of-network, it can make a major difference
in their ultimate costs.
It's
possible that in many of the cases in the study, the lead surgeon had no idea
that some of the people involved in the operation or post-op care were outside
the patient's insurance network.
This
may be especially true for patients who have narrow-network coverage that they
bought on a federal or state marketplace. In the study, more than a quarter of
operations paid for by Marketplace plans involved a surprise bill.
"We
as surgeons need to make sure we are doing right by our patients," Chhabra
says. "This disproportionately affects vulnerable populations, such as
those who have weaker insurance coverage, and those with more health issues.
For them, a surprise bill is adding insult to injury."
He also
notes that provider groups may use out-of-network bills as a bargaining chip to
try to get higher reimbursement from insurers if and when they become part of
their network. Even if they never send the bill for the balance to the patient,
the increased cost to the insurer could mean higher costs for everyone covered
by that company.
What
patients can do
In
light of their findings, the authors advise patients to take care to check
their insurance network, and ask about billing practices, when scheduling an
operation.
If they
receive a surprise bill, they should not shy away from asking the insurance
company to pay the requested charge, asking for discounts or write-offs of their
share of the bill, or filing complaints with state insurance regulators.
More information: JAMA (2020). DOI: 10.1001/jama.2019.21463 ,
https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2019.21463
Journal information: Journal of the
American Medical Association
https://medicalxpress.com/news/2020-02-bills-surgeon-hospital-in-network.html
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