- One in five commercially insured adults undergoing an elective surgery with primary surgeons who were in-network received a surprise medical bill in the past two years, according to research published Tuesday in JAMA.
- Anesthesiologist and surgical assistants, such as physician's assistants and registered nurses, were associated with the most out-of-network charges. Bills from out-of-network surgical assistants averaged $3,633, compared to $1,219 from anesthesiologists.
- The study's authors call for clinicians and Congress to help end the practice of surprise billing as three key pieces of legislation work their way through the chambers. The American Hospital Association said Monday it supports a House Ways and Means Committee proposal that uses arbitration to settle out-of-network claims but does not approve of the Education and Labor Committee's approach that blends in some rate setting aspects.
Congress failed to pass a ban on surprise billing in December, when year-end funding legislation was seen as a likely vehicle, despite a bipartisan push for ending the practice and support from the White House. But lawmakers stalled on determining the best approach between policies that use arbitration (supported by providers) and those that create a set rate for out-of-network services (supported by payers).
Lobbies like AHA and America's Health Insurance Plans, as well as physician staffing groups backed by deep-pocketed private equity firms, have spent furiously to push their preferred approach, and the result has been gridlock. Lawmakers are still pushing out drafts, however, eying a May spending package.
Meanwhile, patients are still receiving unexpected bills asking for high dollar figures.
For the JAMA study, researchers analyzed 347,356 patients who had undergone one of seven common elective operations between 2012 and 2017: an arthroscopic meniscal repair, gallbladder removal surgery, hysterectomy, total knee replacement, breast lumpectomy, surgery to remove part or all of the colon and coronary artery bypass graft surgery.
They found that an out-of-network bill was present in 20.5% of episodes when the primary surgeon and facility were in-network, leaving patients with a mean potential balance bill of $2,011. In many cases, the fees were incurred from an out-of-network surgical assistant or anesthesiologist who assisted with the operation.
Researchers say this is common in surgical settings — surgeons often rely on assistance during operations from other skilled professionals including physician assistants, and these clinicians may bill the patient separately from the primary surgeon.
Out-of-network bills also varied widely across states. Despite enacting policies to stamp out the problem, California and New York all had proportions of out-of-network bills above the national median.
While researchers say those states may have been responding to endemic surprise billing problems, they note that the policies may not have been completely effective due to the Employee Retirement Income Security Act, which preempts states from regulating self-insured plans.
The findings come amid increasing bipartisan legislation in Congress to end the practice, and increasing rhetoric from democratic presidential candidates to overhaul the national healthcare system.
The House Ways and Means Committee's surprise billing proposal came Friday, and has garnered support from groups such as the American College of Emergency Physicians and the AHA. The legislation, scheduled for a markup Wednesday, "protects patients while preserving the appropriate role of providers and insurers in negotiating payment rates," AHA CEO Rick Pollack said in a statement.
But other groups strongly oppose the draft. The ERISA Industry Committee said the proposal "creates a new system that is markedly worse than current law for patients and families."