Surprise billing in intensive care unit (ICU) hospitalizations

Intensive care unit (ICU) care is expensive for patients and providers, and utilization and spending on ICU resources have increased. The No Surprises Act, passed in 2022, specifically prohibits balance billing by ICU specialists (intensivists) for emergency and most non-emergency care. The potential economic impact of this remains unclear, given few data exist on the magnitude of balance billing in the ICU. Using the MarketScan Commercial (IBM) database, we studied hospitalizations in which ICU care was provided ("ICU hospitalizations") between 2010 and 2019. Hospitalizations were characterized as fully in-network, fully out-of-network, or "mixed" (contained both in- and out-of-network services). The share of "mixed" hospitalizations among all ICU hospitalizations rose from 26% to 33% over the study period. Over half of these mixed hospitalizations contained out-of-network services specifically delivered within the ICU. Total hospitalization spending averaged $81 047, with ICU spending averaging $15 799. On average, 11% of ICU spending within these hospitalizations was out-of-network. Patients were plausibly balance-billed in approximately one-third of ICU hospitalizations, for thousands of dollars per hospitalization. Given that the No Surprises Act prevents this type of balance billing, the portended revenue loss may lead to changes in provider negotiations with insurers concerning network status and prices, which could affect the care patients receive.