February 11, 2020 / 9:32 PM / 9 days ago

Surprise surgery bills happen even when patients plan ahead

(Reuters Health) - One in five patients who get elective surgery at U.S. hospitals that accept their insurance may still get surprise medical bills, especially if they receive anesthesia, a new study suggests.

The study looked at what happened to almost 350,000 patients who had non-emergency surgery between 2012 and 2017 at hospitals and clinics that belonged to their health plan network, using surgeons who accepted their insurance.

Even among those who did their best to go where their insurance was accepted, 21% still got surprised by out-of-network bills. And tabs were not small, averaging more than $2,000.

“We had no idea how often this actually happened or how damaging it could be,” said Dr. Karan Chhabra, of the University of Michigan Institute for Healthcare Policy and Innovation in Ann Arbor and Brigham and Women’s Hospital in Boston, who led the study.

At a time when many Americans with private health insurance are being asked to pay more for their care - in the form of higher premiums, co-payments and deductibles - surprise medical bills are commonplace for emergency care and other situations when people are unable to confirm their benefits in advance.

But the current study offers fresh evidence that surprise bills can arrive even after people plan ahead and schedule procedures where their benefits should be accepted, researchers note in JAMA.

“They might expect not to have any problems paying for care if they make sure their surgeon and the hospital are in-network,” Chhabra said by email. “Our study shows that is not the case.”

Patients got several common types of surgery, including knee operations, removal of a lump from the breast and procedures to improve blood flow to the heart.

In more than one-third of cases when patients got surprise bills, a surgical assistant or anesthesiologist was the source. In these cases, the primary surgeon accepted the patient’s insurance but other clinicians did not.

Surprise out-of-network bills averaged $3,633 when surgical assistants didn’t accept patients’ insurance and $1,219 when anesthesiologists were the ones out-of-network, the study found.

People with insurance plans purchased through health exchanges got surprise bills 27% of the time, compared with 20% of the time with other types of private health coverage.

Surgical complications made surprise bills more likely, resulting in unexpected bills 28% of the time, compared with 20% when operations went off without problems.

One limitation of the study is that it only included data from patients with benefits from one insurance company, the researchers note. The data also didn’t indicate whether patients understood they had received out-of-network care or what portion of any resulting bills they may have paid.

It’s not clear from the study exactly why patients received surprise bills or what they might do to avoid them, said Michelle Mello, a health policy researcher at Stanford University School of Medicine who wasn’t involved in the new research.

One thing patients can do, however, is think carefully about whether it makes sense for them to purchase what’s known as a “narrow network” plan, which might have lower premiums but a very limited number of in-network providers and steep fees for getting care outside the network, Mello said by email.

“While their premiums are affordable, there are countervailing costs: you may have to wait a lot longer to see a specialist, for example; and there’s a higher risk that the people who take care of you in the hospital won’t all be in network,” Mello said.

People should also ask their surgeons, hospitals and insurance companies about out-of-network billing, Mello advised. Hospitals should be able to explain whether an elective surgery might involve out-of-network clinicians.

And people shouldn’t just pay the surprise bills without protest.

“Make a stink,” Mello advised. “It’s often possible to negotiate these down.”

SOURCE: bit.ly/2OMkn3Z , bit.ly/37ge536 and bit.ly/2UPqgRX JAMA, online February 11, 2020.

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