About 10% of patients with in-network surgeons had out-of-network facility charges for TJA
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Published results showed more than 10% of patients who received total joint arthroplasty care from an in-network surgeon had out-of-network facility charges.
Using the MarketScan commercial claims database, Eric L. Smith, MD, FAOA, and colleagues collected demographic, geographic, operative, insurance, temporal and financial details of 13,031 patients who underwent outpatient total hip or knee arthroplasty for osteoarthritis at either an ASC or hospital outpatient department from 2007 to 2017. Researchers reviewed the trend of out-of-network facility utilization over time and compared the prevalence of out-of-network facilities between ASCs and hospital outpatient departments with adjusted regressions.
Results showed a significant decrease in utilization of out-of-network facilities from 27.8% of surgeries in 2007 to 9.7% in 2017. However, researchers found this decrease to be non-linear, with a significant increase in the use of out-of-network ASCs in 2013 (20.8%) and 2014 (27.5%) before decreasing again in 2015 (20%) and 2016 (13.7%). Patients were significantly more likely to be out of network when treated at an ASC vs. a hospital outpatient department, according to results.
Researchers noted 4.5% of 11,136 patients treated at in-network hospitals had an out-of-network surgeon, while 10.4% of 11,870 patients being treated by in-network surgeons were treated at an out-of-network facility. Results showed patients who underwent outpatient TJA at an out-of-network facility had a mean potential balance bill of $11,566.
“Over 10% of patients receiving care by in-network surgeons face out-of-network facility charges. These out-of-network facility charges are incurred primarily at ASCs. These charges may come as a surprise to patients,” Smith told Healio Orthopedics. “We believe that insurers should work to expedite contracting with ASCs to increase access and to minimize potential surprise billing. We believe that surgeons performing outpatient TJA at ASCs should review their facility network status with their patients to avoid potential out-of-network charges.”
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Despite all of the recent political controversy in Washington D.C., legislators have been working on a bipartisan solution for surprise medical billing during the past year. Nathan H. Varaday, SB, and colleagues highlight this issue in their timely study finding that more than 10% of THA and TKA patients in ASCs faced out-of-network charges.
No orthopedic surgeon wants their patient stuck with a $25,000 medical bill, and the American Association of Orthopaedic Surgeons and the American Association of Hip and Knee Surgeons have both been fighting for patients on this issue. Many physician practices have worked hard to negotiate an in-network ASC rate with payers, as evidenced by a declining out-of-network trend in this study. The COVID relief bill passed in December 2020 allowed for independent dispute resolution to help resolve out-of-network payment disagreements between providers and insurance companies. This process has worked well in New York; however, the arbitrator will consider the median in-network rate for each procedure. This may disincentivize insurance companies from negotiating in-network rates with providers in the future if defaulted to their own average rate. Future policy discussions should ensure that surgeons and ASCs are not penalized for providing high-quality, low-cost THA and TKA care.
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