- A new study reports that 20 percent of hospital bills can contain surprise charges, even for people who are fully insured.
- The researchers say many of the higher charges involve “surgical assistants” and other ancillary personnel who aren’t in a patient’s network coverage.
- Experts urge people to check their insurance company’s network providers and ask for a detailed statement of upfront costs before a medical procedure.
Going to the emergency room is rarely a fun experience.
First, there’s the reason you need to go: a medical emergency, whether from an accident, an exasperated preexisting condition, or a host of other causes.
But once you’re stabilized and deemed fit to go home, there’s another kind of uncertainty: the bills that will follow, even if you’re fully insured.
Because people are less likely to be able to choose their in-network provider in an emergency situation, the situation is wrought with all sorts of potential behind-the-scenes contract loopholes.
These include an out-of-network doctor or nurse working at an in-network facility, according to a 2017 paper by Yale University researchers.
But a new study shows similar surprise bills are commonly sent to people who underwent planned, nonemergency surgeries performed by an in-network doctor at an in-network facility.
New research
In the new study, researchers from the University of Michigan used claims to a large, unnamed insurance company from in-network and out-of-network medical providers for more than 347,000 patients under age 65.
Each of those patients had one of seven common, nonemergency operations at an in-network hospital or outpatient surgery center between 2012 and 2017.
Researchers found that while the lead surgeons and the facilities they operated at were in a patient’s insurance network, 20 percent of the procedures led to an out-of-network bill.
On average, that surprise bill was $2,011 more than the $1,800 the average privately insured person would already owe after their insurance company paid for most of the costs of their operation.
The surprise bills don’t come from the hospital or the surgeon. They come through other employees at the facility who may not be in a person’s insurance network.
The study notes that patients who had postsurgery complications were more likely to have surprise out-of-network bills.
The Michigan researchers found the average potential surprise bill ranged from $86 for medical imaging specialists involved in a hysterectomy to more than $8,000 for surgical assistants involved in a breast lumpectomy.
Those “surgical assistants” — a catchall term for hospital employees with hands-on involvement in the operation or postoperative care — accounted for more than two-thirds of all surprise bills, something the researchers said they were “especially surprised” to learn.
The average bill for those surgical assistants, if they were out of network, was $3,633.
And there are some people who pay much more.
If the patient had an outpatient procedure with an in-network surgeon but it took place at an ambulatory surgery center that was out-of-network, the potential surprise bill could add up to more than $19,000.
Dr. Karan Chhabra, the study’s first author and a National Clinician Scholar at the University of Michigan’s Institute for Healthcare Policy and Innovation, says the findings shine a light on the need for federal-level measures to address surprise billing.
“These are eye-popping numbers, which most clinicians are likely unaware of and which patients can’t prepare for,” Chhabra said in a statement.
“We, as surgeons, need to make sure we are doing right by our patients. This disproportionately affects vulnerable populations, such as those who have weaker insurance coverage and those with more health issues. For them, a surprise bill is adding insult to injury,” he said.
Besides federal laws to protect against surprise bills, the Michigan researchers say there are several ways consumers can be proactive before their procedure.
These include checking their insurance company’s network and billing practices, and filing complaints with state insurance regulators.
But Chhabra says the new research suggests no one is apparently immune from a surprise medical bill.
“Even if patients do their homework before they have elective surgery, this study shows they can be at risk of receiving large bills they never expected, from providers they never met or even knew about,” he said.
Anthony Lopez is the senior director of individual and family plans at eHealth, the nation’s largest private health insurance exchange.
He says consumers should make sure their providers are in-network, get pre-authorization for the procedure if necessary, and ask for an estimate of the total costs upfront.
“An estimate of costs will not typically guarantee your final out-of-pocket expenses, but it gives you a more informed view of your total costs,” Lopez told Healthline.
But if a person is hit with a surprise bill, Lopez recommends trying to negotiate with the hospital.
“Oftentimes, medical providers will accept payment lower than the total bill. In fact, that’s how most insurance works already,” he said. “Providers know they may not get the full amount and are often willing to meet you halfway.”
Bill Kramer, executive director for national health policy at the Pacific Business Group on Health, says while the first priority should be to protect patients from surprise billing, there’s only so much individuals can do to prevent surprise bills or negotiate lower payments.
Besides consumers having to be extra careful, he says federal legislators need to work to stop the practice altogether.
“Congress must step in to protect patients from the egregious practice of surprise billing,” Kramer told Healthline. “Furthermore, they should not allow providers to simply pass on outrageously high prices to health plans and employers; that simply raises the monthly premiums for all consumers and patients.”