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Out-of-Network Billing Common for Surgery Within Network

Bills for about one in five undergoing elective ops performed with in-network primary surgeon, facility

TUESDAY, Feb. 11, 2020 (HealthDay News) -- About one in five patients undergoing common elective operations performed with in-network primary surgeons and facilities have an out-of-network bill, according to a study published in the Feb. 11 issue of the Journal of the American Medical Association.

Karan R. Chhabra, M.D., from the University of Michigan in Ann Arbor, and colleagues examined out-of-network billing across common elective operations performed with in-network primary surgeons and facilities. Data were included for 347,356 patients who had undergone one of seven common elective operations.

The researchers found that 20.5 percent of the episodes had an out-of-network bill, with a mean potential balance bill of $2,011 per episode when present. Out-of-network bills were associated with surgical assistants and anesthesiologists in 37 percent (each) of these episodes; when present, the mean potential balance bills were $3,633 and $1,219, respectively. Compared with nonexchange plans, membership in health insurance exchange plans correlated with a significantly increased risk for out-of-network bills (27 versus 20 percent). The risk for out-of-network bills was increased in association with surgical complications versus no complications (28 versus 20 percent). Overall, 6.7 percent of 83,021 procedures carried out at ambulatory surgery centers with in-network primary surgeons included an out-of-network facility bill.

"Clinicians and policy makers alike should act to end this practice. First, surgeons have an ethical responsibility to speak out against surprise billing," write the authors of an accompanying editorial. "Second, Congress needs to act to eliminate surprise billing."

One author is a cofounder of ArborMetrix.

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