Our expert answers 3 Questions
I'm thinking about how we can make healthcare more affordable in this country. Even as more Americans have gained health insurance coverage under the Affordable Care Act, lots of people are still struggling to pay for their healthcare. Not only that, but they're often avoiding care because of anticipated expenses or because they’re saddled with bills from care they’ve already received.
As a surgeon, I'm particularly interested in out-of-pocket spending around surgery, and much of my research has focused on how much insured patients are paying for surgical care, and what we can do about it. Even with insurance, people are being asked to pay for more and more of their care out-of-pocket. On top of that, often the care that people need or the doctors they are seeing are not covered by their plans.
For most people with health insurance, some doctors are covered by your insurance, and some are not. Usually, if you’re going to get a checkup or an office visit, you can find out ahead of time whether your doctor takes your insurance—whether they’re “in-network”—and go somewhere else if they’re out-of-network.
But these bills become a “surprise” when you try to seek out doctors and hospitals that are in your network, but still get bills from providers who are out-of-network. Those providers can charge you whatever they think they deserve, and if your insurance pays them less than they ask for, they can legally “balance bill” you for the difference in many states.
This “surprise medical billing” often happens in emergency care settings, or after emergency transport to a healthcare facility – situations where people don’t have much control over whether the service providers are in-network.
But we’re finding it also happens in circumstances when patients have chosen in-network providers or facilities but out-of-network providers are brought in to participate in their care – often without their knowledge. Surgical care, for example, typically involves a breadth of different providers besides the surgeon – from the anesthesiologist, to the radiologist, to the pathologist, to assistant surgeons – who are all billing for their aspect of the case, and could all potentially be out-of-network. Even if patients have chosen in an-network surgeon for an elective procedure, they can’t make informed choices about who’s taking care of them once they’re asleep.
Our research shows that surprise bills in elective surgery are equally common and significantly larger than those in emergency care, happening in roughly 1 in 5 procedures, and averaging $2,000. These trends were consistent across a range of common procedures, from hysterectomies to knee replacement. Surgical assistants and anesthesiologists were most commonly involved in these surprise bills.
From a public policy perspective, Congress could craft a legislative fix to help address the current surprise billing situation, and has been working on a number of potential solutions. While several states have passed provisions that provide some protection from surprise bills, on their own, state-based policies don’t apply to self-insured plans – which make up 60 percent of employer-sponsored insurance – because those plans are regulated by a federal law called ERISA.
From a provider perspective, surgeons can reduce the risk of surprise bills by choosing to work with in-network doctors, especially surgical assistants. Some hospitals are making efforts to ensure that all their doctors all participate in the same insurance plans. Meanwhile, patients can try to be proactive in asking their doctors and hospitals whether they accept their insurance, with the caveat that it can be impossible to anticipate situations where other providers become involved who don’t participate in their insurance. People who do receive surprise out-of-network bills should know there are options to address them in many states through a consumer helpline or an arbitration process. Patients may also be able to negotiate these bills down directly with their doctors and insurance companies.