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Out-of-Network Bills for Privately Insured Patients Undergoing Elective Surgery With In-Network Primary Surgeons and Facilities
JAMA ( IF 120.7 ) Pub Date : 2020-02-11 , DOI: 10.1001/jama.2019.21463 Karan R Chhabra 1, 2, 3, 4 , Kyle H Sheetz 2, 5 , Ushapoorna Nuliyalu 2 , Mihir S Dekhne 4 , Andrew M Ryan 2, 6, 7 , Justin B Dimick 2, 5
JAMA ( IF 120.7 ) Pub Date : 2020-02-11 , DOI: 10.1001/jama.2019.21463 Karan R Chhabra 1, 2, 3, 4 , Kyle H Sheetz 2, 5 , Ushapoorna Nuliyalu 2 , Mihir S Dekhne 4 , Andrew M Ryan 2, 6, 7 , Justin B Dimick 2, 5
Affiliation
Importance
Privately insured patients who receive care from in-network physicians may receive unexpected out-of-network bills ("surprise bills") from out-of-network clinicians they did not choose. In elective surgery, this can occur if patients choose in-network surgeons and hospitals but receive out-of-network bills from other involved clinicians. Objective
To evaluate out-of-network billing across common elective operations performed with in-network primary surgeons and facilities. Design, Setting, and Participants
Retrospective analysis of claims data from a large US commercial insurer, representing 347 356 patients who had undergone 1 of 7 common elective operations (arthroscopic meniscal repair [116 749]; laparoscopic cholecystectomy [82 372]; hysterectomy [67 452]; total knee replacement [42 313]; breast lumpectomy [18 018]; colectomy [14 074]; coronary artery bypass graft surgery [6378]) by an in-network primary surgeon at an in-network facility between January 1, 2012, and September 30, 2017. Follow-up ended November 8, 2017. Exposure
Patient, clinician, and insurance factors potentially related to out-of-network bills. Main Outcomes and Measures
The primary outcome was the proportion of episodes with out-of-network bills. The secondary outcome was the estimated potential balance bill associated with out-of-network bills from each surgical procedure, calculated as total out-of-network charges less the typical in-network price for the same service. Results
Among 347 356 patients (mean age, 48 [SD, 11] years; 66% women) who underwent surgery with in-network primary surgeons and facilities, 20.5% of episodes (95% CI, 19.4%-21.7%) had an out-of-network bill. In these episodes, the mean potential balance bill per episode was $2011 (95% CI, $1866-$2157) when present. Out-of-network bills were associated with surgical assistants in 37% of these episodes; when present, the mean potential balance bill was $3633 (95% CI, $3384-$3883). Out-of-network bills were associated with anesthesiologists in 37% of episodes; when present, the mean potential balance bill was $1219 (95% CI, $1049-$1388). Membership in health insurance exchange plans, compared with nonexchange plans, was associated with a significantly higher risk of out-of-network bills (27% vs 20%, respectively; risk difference, 6% [95% CI, 3.9%-8.9%]; P < .001). Surgical complications were associated with a significantly higher risk of out-of-network bills, compared with episodes with no complications (28% vs 20%, respectively; risk difference, 7% [95% CI, 5.8%-8.8%]; P < .001). Among 83 021 procedures performed at ambulatory surgery centers with in-network primary surgeons, 6.7% (95% CI, 5.8%-7.7%) included an out-of-network facility bill and 17.2% (95% CI, 15.7%-18.8%) included an out-of-network professional bill. Conclusions and Relevance
In this retrospective analysis of commercially insured patients who had undergone elective surgery at in-network facilities with in-network primary surgeons, a substantial proportion of operations were associated with out-of-network bills.
中文翻译:
通过网络内初级外科医生和设施接受选择性手术的私人保险患者的网络外账单
重要性 接受网络内医生护理的私人保险患者可能会收到他们未选择的网络外临床医生的意外网络外账单(“意外账单”)。在择期手术中,如果患者选择网络内的外科医生和医院,但从其他相关临床医生那里收到网络外的账单,就会发生这种情况。目的 评估网络内初级外科医生和设施执行的常见选择性手术的网络外计费。设计、设置和参与者 对来自美国一家大型商业保险公司的索赔数据进行回顾性分析,代表 347 356 名接受过 7 种常见择期手术(关节镜半月板修复术 [116 749];腹腔镜胆囊切除术 [82 372];子宫切除术 [67])中的 1 次的患者452];全膝关节置换术 [42 313];乳房肿块切除术 [18 018];结肠切除术 [14 074]; 2012 年 1 月 1 日至 2017 年 9 月 30 日期间,网络内主要外科医生在网络内设施接受冠状动脉旁路移植手术 [6378]。随访于 2017 年 11 月 8 日结束。暴露患者、临床医生和保险可能与网络外账单相关的因素。主要结果和措施主要结果是发生网络外账单的比例。次要结果是与每次手术的网络外账单相关的估计潜在余额账单,计算方式为网络外费用总额减去相同服务的典型网络内价格。结果 在 347 356 名接受网络内初级外科医生和设施手术的患者(平均年龄,48 [SD,11] 岁;66% 为女性)中,20.5% 的发作(95% CI,19.4%-21.7%)有网外账单。在这些剧集中,每集的平均潜在余额账单为 2011 美元(95% CI,1866-2157 美元)。在这些事件中,37% 的网络外账单与外科助理有关;当存在时,平均潜在余额账单为 3633 美元(95% CI,3384-3883 美元)。在 37% 的事件中,网络外账单与麻醉师有关;当存在时,平均潜在余额账单为 1219 美元(95% CI,1049-1388 美元)。与非交换计划相比,健康保险交换计划的会员资格与网络外账单风险显着更高相关(分别为 27% 和 20%;风险差异,6% [95% CI,3.9%-8.9%) ];P < .001)。与无并发症的发作相比,手术并发症与网络外账单风险显着升高相关(分别为 28% 和 20%;风险差异、7% [95% CI,5.8%-8.8%];P < .001)。在具有网络内初级外科医生的门诊手术中心进行的 83 021 例手术中,6.7%(95% CI,5.8%-7.7%)包括网络外设施账单,17.2%(95% CI,15.7%-18.8 %) 包括网络外专业账单。结论和相关性 在这项对商业保险患者的回顾性分析中,这些患者在网络内设施接受了网络内初级外科医生的择期手术,很大一部分手术与网络外账单相关。
更新日期:2020-02-11
中文翻译:
通过网络内初级外科医生和设施接受选择性手术的私人保险患者的网络外账单
重要性 接受网络内医生护理的私人保险患者可能会收到他们未选择的网络外临床医生的意外网络外账单(“意外账单”)。在择期手术中,如果患者选择网络内的外科医生和医院,但从其他相关临床医生那里收到网络外的账单,就会发生这种情况。目的 评估网络内初级外科医生和设施执行的常见选择性手术的网络外计费。设计、设置和参与者 对来自美国一家大型商业保险公司的索赔数据进行回顾性分析,代表 347 356 名接受过 7 种常见择期手术(关节镜半月板修复术 [116 749];腹腔镜胆囊切除术 [82 372];子宫切除术 [67])中的 1 次的患者452];全膝关节置换术 [42 313];乳房肿块切除术 [18 018];结肠切除术 [14 074]; 2012 年 1 月 1 日至 2017 年 9 月 30 日期间,网络内主要外科医生在网络内设施接受冠状动脉旁路移植手术 [6378]。随访于 2017 年 11 月 8 日结束。暴露患者、临床医生和保险可能与网络外账单相关的因素。主要结果和措施主要结果是发生网络外账单的比例。次要结果是与每次手术的网络外账单相关的估计潜在余额账单,计算方式为网络外费用总额减去相同服务的典型网络内价格。结果 在 347 356 名接受网络内初级外科医生和设施手术的患者(平均年龄,48 [SD,11] 岁;66% 为女性)中,20.5% 的发作(95% CI,19.4%-21.7%)有网外账单。在这些剧集中,每集的平均潜在余额账单为 2011 美元(95% CI,1866-2157 美元)。在这些事件中,37% 的网络外账单与外科助理有关;当存在时,平均潜在余额账单为 3633 美元(95% CI,3384-3883 美元)。在 37% 的事件中,网络外账单与麻醉师有关;当存在时,平均潜在余额账单为 1219 美元(95% CI,1049-1388 美元)。与非交换计划相比,健康保险交换计划的会员资格与网络外账单风险显着更高相关(分别为 27% 和 20%;风险差异,6% [95% CI,3.9%-8.9%) ];P < .001)。与无并发症的发作相比,手术并发症与网络外账单风险显着升高相关(分别为 28% 和 20%;风险差异、7% [95% CI,5.8%-8.8%];P < .001)。在具有网络内初级外科医生的门诊手术中心进行的 83 021 例手术中,6.7%(95% CI,5.8%-7.7%)包括网络外设施账单,17.2%(95% CI,15.7%-18.8 %) 包括网络外专业账单。结论和相关性 在这项对商业保险患者的回顾性分析中,这些患者在网络内设施接受了网络内初级外科医生的择期手术,很大一部分手术与网络外账单相关。