February 20, 2020
2 min read

‘Substantial’ percentage operations at in-network facilities received out-of-network bills

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Karan R. Chhabra

Published results showed a “substantial” proportion of commercially insured patients received out-of-network bills for operations performed at in-network facilities with in-network primary surgeons.

Karan R. Chhabra, MD, MSc, and colleagues retrospectively reviewed claims data from a large U.S. commercial insurer for 347,356 patients younger than 65 years of age who underwent arthroscopic meniscal repair, laparoscopic cholecystectomy, hysterectomy, total knee replacement, breast lumpectomy, colectomy or coronary artery bypass graft surgery by an in-network primary surgeon at an in-network facility. Researchers considered the proportion of episodes with out-of-network bills as the primary outcome and the estimated potential balance bill associated with out-of-network bills from each surgical procedure as secondary outcomes.

Results showed 20.5% of episodes had an out-of-network bill despite being performed by an in-network primary surgeon at an in-network facility, with a mean potential balance bill per episode of $2,011 when present. Researchers found 37% of episodes had out-of-network claims for both anesthesiologists and surgical assistants. The mean potential balance bill was $1,219 for anesthesiologists and $3,633 for surgical assistants, according to results.

“In this retrospective analysis of commercially insured patients who had undergone elective surgery at in-network facilities within-network primary surgeons, a substantial proportion of operations were associated without-of-network bills,” the authors wrote in their study.

A 'substantial' proportion of insured  patients received out-of-network bills for procedures performed at in-network facilities with in-network primary surgeons. 

Researchers noted a significantly higher risk of out-of-network bills among patients with membership in health insurance exchange plans compared with nonexchange plans and surgical complications compared with episodes with no complications. Results showed 6.7% of 83,021 procedures performed at ASCs with in-network primary surgeons included an out-of-network facility bill, while 17.2% included an out-of-network professional bill.

“Even if patients do their homework before they have elective surgery, this study shows they can be at risk for receiving large bills they never expected, from providers they never met or even knew about,” Chhabra said in a press release.

He added that many times, the lead surgeon may not know some of the individuals involved in the operation or postoperative care are outside the patient’s insurance network, especially for patients with narrow-network coverage bought on a federal or state marketplace.

“We, as surgeons, need to make sure we are doing right by our patients,” Chhabra said in the release. “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.” – by Casey Tingle


Disclosures: Chhabra reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.