Prevalence And Characteristics Of Surprise Out-Of-Network Bills From Professionals In Ambulatory Surgery Centers.

Area of Science:

• Health Services Research
• Health Economics
• Patient Financial Protection

Background:

• Patients treated at in-network facilities may receive unexpected bills from out-of-network providers.
• Previous research has focused on surprise billing in emergency and inpatient settings, neglecting ambulatory surgery centers (ASCs).
• The financial burden and prevalence of out-of-network billing in ASCs remain largely undocumented.

Purpose of the Study:

• To determine the prevalence of surprise medical bills in ambulatory surgery centers.
• To investigate the extent to which health plans cover out-of-network provider charges in ASCs.
• To identify providers contributing most to potential surprise bills in ASCs.

Main Methods:

• Analysis of 4.2 million ASC-based episodes of care from 2014-2017.
• Inclusion of data from 3.3 million patients enrolled in major commercial health plans (UnitedHealth Group, Humana, Aetna).
• Examination of out-of-network ancillary provider involvement and insurer payment patterns.

Main Results:

• One in ten ASC episodes involved out-of-network ancillary providers at in-network facilities.
• Potential surprise bills occurred in 8% of in-network ASC episodes after accounting for insurer payments.
• The average potential surprise bill per episode increased significantly from $819 in 2014 to $1,483 in 2017.
• Anesthesiologists, certified registered nurse anesthetists, and independent laboratories were primary sources of surprise bills.

Conclusions:

• Surprise medical billing is a significant issue in ambulatory surgery centers, impacting a notable percentage of patients.
• The financial exposure for patients due to out-of-network providers in ASCs is substantial and increasing.
• Federal policy is needed to extend surprise bill protections to all commercially insured patients undergoing procedures in ASCs.