JAMA study: One in five elective surgery patients receive a surprise medical bill

Over 20% of commercially insured adults who underwent a common in-network surgical procedure between January 2012 and September 2017 received surprise charges for the episode from out-of-network clinicians, according to a recent study published in JAMA. 

Privately insured patients who receive care from in-network physicians may receive unexpected out-of-network bills (“surprise bills”) from out-of-network clinicians they did not choose. To evaluate out-of-network billing across common elective operations performed with in-network surgeons, researchers retrospectively analyzed claims data from a large U.S. commercial insurer. They reviewed claims for 347,356 patients who underwent one of seven common elective operations by an in-network primary surgeon at an in-network facility between January 1, 2012, and September 30, 2017. The primary outcome was the number of episodes that resulted in out-of-network bills.

Reviewed claims were for the following elective procedures:

• Arthroscopic meniscal repairs (116,749)
• Laparoscopic cholecystectomies (82,372)
• Hysterectomies (67,452)
• Total knee replacements (42,313)
• Breast lumpectomies (18,018)
• Colectomies (14,074)
• Coronary artery bypass graft surgeries (6,378)

Researchers found that an out-of-network bill was present in 20.5% of episodes when the primary surgeon and facility were in-network. The average out-of-network bill per episode was $2,011. 

Most out-of-network charges were associated with work performed by anesthesiologists and surgical assistants such as physician's assistants and registered nurses. Bills for out-of-network care averaged $3,633 when performed by a surgical assistant, and $1,219 when performed by an anesthesiologist.

The study authors ask clinicians and Congress to help end the practice of surprise billing. Notably, their findings come amid increasing bipartisan legislation in Congress to put an end to out-of-network billing practices. On February 7, the House Ways & Means Committee released the Consumer Protections Against Surprise Medical Bills Act of 2020— its proposal to curb surprise medical billing, which includes a provision to establish an independent mediated negotiation process for billing disagreements.