Patients who schedule elective surgery at an in-network facility with an in-network primary surgeon are often subjected to surprise medical bills because other members of the surgical teams were out-of-network, a study published Tuesday shows.
The trend extended to states that had passed laws aimed and protecting patients from surprise medical bills. And it comes as debate in Congress is heating up again over how federal lawmakers can best curtail the problem.
Researchers at the University of Michigan and a student at Harvard Medical School found that 20.5% of patients who underwent one of seven common elective surgeries received a surprise medical bill, according to claims data from a major health insurer for January 2012 through September 2017. The research, published in JAMA, shows that balance billing could also be prevalent in non-emergency settings.
"This is in contrast to prior research on emergency care, which pointed toward a subset of emergency departments staffed by private equity-backed medical groups as the primary source of out-of-network billing," the authors wrote.
The average amount of a surprise bill was $2,011. Out-of-network surgical assistants were present in 37% of the balance-billing instances, and associated bills were an average of $3,633. Anesthesiologists also were involved in 37% of balance-billing situations, and the average surprise bill was $1,219.
Though states such as California, Connecticut, Florida, Illinois, Maryland, Massachusetts, Mississippi and New York have enacted varying laws protecting patients from surprise medical bills, all had proportions of surprise billing above the national median for elective surgery with an in-network facility and primary surgeon.
"This suggests several hypotheses, including that these states may have been responding to endemic surprise billing problems, and that these policies may not have been completely effective," the study authors wrote.
Federal surprise billing proposals currently take different approaches to address surprise bills for elective procedures.
The House Ways & Means proposal would require plans to provide enrollees with an explanation of benefits, including a cost estimate, for services scheduled at least three days in advance.
Hospitals and providers have started to line up behind the Ways & Means bill. The American Hospital Association, Federation of American Hospitals, Greater New York Hospital Association and American College of Emergency Physicians have made supportive statements about the bill. American Society of Anesthesiologists President Dr. Mary Dale Peterson said the group is "certainly interested" in the proposal.
Compromise legislation from the House Energy & Commerce Committee and Senate health committee would ban some out-of-network providers at in-network facilities from balance billing unless the provider notifies the patient of network status and provides a cost estimate at least 72 hours in advance.
Insurers and employers generally would prefer an approach addressing surprise medical bills similar to the one taken by the House Energy & Commerce Committee, though they do not like that an arbitration process was included for claims with an in-network payment of at least $750.
Several factors affected patients' risk of receiving a surprise medical bill, according to the JAMA study. Enrollees in exchange health insurance plans were more likely to be surprise billed than those in non-exchange plans because exchange plans generally have narrower physician networks; those with surgical complications were also likely to face surprise medical bills. Balance bills also varied state-by-state, ranging from a 3% incidence rate in Nebraska to 46% in Alaska.
The JAMA study authors were Dr. Karan Chhabra, Dr. Kyle Sheetz, Ushapoorna Nuliyalu, Mihir S. Dekhne, Andrew Ryan, and Dr. Justin Dimick.