One in 5 Elective In-Network Surgeries Result in Out-of-Network Bill

February 11, 2020
Peter Wehrwein
Peter Wehrwein

Twenty percent of seven in-network elective surgeries for a large national insurer resulted in a “surprise” out-of-network bill; averaging at $2,011.

Twenty percent of seven in-network elective surgeries for a large national insurer resulted in a “surprise” out-of-network bill, according to research results reported in today’s JAMA.

The average bill was $2,011. Clinicians that assisted with surgery and anesthesiologists were most common sources of the out-of-network bills.

Karan Chhabra of the University of Michigan and author of the study, and her colleagues, reported their results as various bills to curb surprise billing are being debated in Congress. Last Friday, the leadership of the House Ways and Means Committee unveiled a bill that would prohibit balance billing and establish an arbitration process for insurers and providers that are fighting over out-of-network payment. A competing bill from the House Education and Labor Committee came out the same day. It would set benchmark payments up for out-of-network bills up to $750 and an arbitration process for larger amounts.

Related: Trump’s Price Transparency Rules: What Health Execs Need to Know

Most of the attention has been on surprise billing for emergency care when patients may not have much, if any, choice about where they are treated.

But the study by Chhabra and his colleagues shows that out-of-network bills are not uncommon when it comes to elective surgery. They conducted their study by combing through claims for 347,356 patients who had one of seven different types of elective surgery: arthroscopic meniscal repair, laparoscopic cholecystectomy, hysterectomy, total knee replacement, breast lumpectomy, colectomy, and coronary artery bypass. The claims were for surgeries conducted by an in-network surgeon in an in-network facility between Jan. 1, 2012, and Sept. 30, 2017. Their winnowing of those claims identified 71,228 that were associated with an out-of-network bill-despite the primary surgeon and the facility being in-network.

One pattern Chhabra and his colleagues saw was simpler ambulatory surgeries (arthroscopic meniscal repair, breast lumpectomy) tended to generate fewer out-of-network bills than complicated, inpatient surgeries (hysterectomy, total knee replacement, colectomy, and CABG). Between 13% and 15% of the simpler surgeries were associated with an out-of-network bill compared with 24% to 33% of the more complicated procedures. Not surprisingly the complicated cases were also associated with higher bills, ranging from $2,000 to $4,000.

These findings fit another finding: That 37% of the out-of-network bills came from “surgical assistants” who helped the primary surgeon. Anesthesiologists were also involved in 37% of the out-of-network bills.

Chhabra and his colleagues used Optum’s Clinformatics DataMart database to conduct their study, so one limitation of their research is that it was limited to a single insurer.