As if recovering from surgery wasn't hard enough, a new study shows that one in five operations could result in an unwelcome surprise: a bill for hundreds or thousands of dollars that the patient didn't know they might owe.
On average, that potential surprise bill added up to $2,011, a team from the University of Michigan reports in the new issue of JAMA . That's on top of the nearly $1,800 the average privately insured patient would already owe after their insurance company paid for most of the costs of their operation.
All the patients in the study chose a surgeon who accepts their insurance, and had one of seven common, non-emergency operations at an in-network hospital or at an outpatient surgery center.
But they still ended up potentially owing large sums to pay other people involved in their operation or their follow-up care . The average potential surprise bill ranged from $86 for medical imaging specialists involved in a hysterectomy, to more than $8,000 for surgical assistants involved in a breast lumpectomy. These out-of-network bills were significantly more common for patients who had complications after surgery.
If the patient had an outpatient procedure with an in-network surgeon, but it took place at an ambulatory surgery center that was out-of-network, the potential surprise bill could add up to more than $19,000.
"These are eye-popping numbers, which most clinicians are likely unaware of, and which patients can't prepare for," says Karan Chhabra, M.D., M.Sc., the study's first author and a National Clinician Scholar at the U-M Institute for Healthcare Policy and Innovation, which funded the study.
The study looked at the claims that a large insurance company received from in-network and out-of-network medical providers for more than 347,000 patients under age 65 who had one of the seven operations between 2012 and 2017. Even though all the lead surgeons and the surgery locations were in-network, 20.5% of the operations led to an out-of-network bill.
The researchers couldn't see the actual "balance bills" that patients were told they must pay, which may vary depending on the insurance plan's provisions. Some insurers may pay part of the bill for out-of-network providers, while others charge patients for the entire added cost.
For the study, the researchers tallied all out-of-network charges billed to the insurer for the care episode related to each operation, and deducted the insurer's typical payment for that care. State and federal implications
The findings shine a light on the need for federal-level measures to address surprise billing, says Chhabra, a research fellow in the Department of Surgery at Michigan Medicine, U-M's academic medical center, and a house officer at Brigham and Women's Hospital in Boston.
That's because state-level policies can't regulate what are called self-insured health insurance plans – the kind of plan that covers most people who get insurance through their jobs or the job of a family member.
Congressional committees have worked on legislation to address surprise billing but have still not agreed on a final legislative fix, though several states have passed provisions that provide some protection.
Depending on what state the patient lives in, the risk of getting a surprise bill differed. In some states, less than 10% of the operations covered by the insurer led to a surprise bill, while in others more than a third did. Southern states had the highest proportion of surprise bills. The team matters, not just the lead surgeon
Even if a patient takes care to choose an in-network surgeon, and an in-network hospital or surgery center, they have little to no control over the rest of the team involved in their care, and whether they take part in their insurance plan. This study reveals the extent and size of the bills that these other providers can incur if they're not in-network." Justin Dimick, M.D., M.P.H., senior author of the new paper, U-M surgery chair Related Stories
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