The study was published online today as a research letter in the Annals of Internal Medicine.
Nearly 1 in 8 commercially insured patients who had an elective colonoscopy between 2012 and 2017 received an out-of-network bill, resulting in hundreds of dollars more than the typical insurance payment.
The median surprise bill was $418 (range $152-$981).
The findings are “disconcerting” say the authors, “because Section 2713 of the Patient Protection and Affordable Care Act eliminates consumer cost sharing for screening colonoscopy, and because a recent Federal Reserve study reported that 40% of Americans do not have $400 to cover unnecessary expenses.”
Most of these surprise costs were incurred from the use of out-of network anesthesiologists and pathologists, the authors note.
“Doctors need to be aware of these out-of-network bills so that patients know what to expect when they undergo these screening procedures,” said study author Karan R. Chhabra, MD, MSc, a resident in general surgery at Brigham and Women’s Hospital, Boston, Massachusetts. “Ideally, they should do their colonoscopies at facilities where all providers participate in the same major insurance plans.”
“If gastroenterologists own their endoscopy facility, this is an obvious situation in which they should not be working with anesthesiologists or pathologists who are not in the same networks as them,” he told Medscape Medical News. “And as we point out in our paper, anesthesiology and pathology review are not necessary in every single case — endoscopists can perform their own sedation, and in certain settings, lesions can be discarded without pathological examination.”
But is it really that simple for physicians to make sure that all members of the team are in-network?
It’s not simple at all, and in fact it’s a rather difficult task, said Glenn Melnick, PhD, professor and chair in health care finance at USC and director of USC’s Center for Health Financing, Policy, and Management in Los Angeles.
“It would be really difficult for Dr Smith to know that Dr Jones is out of network, so it’s really hard to hold the doctors responsible,” Melnick told Medscape Medical News. “There are so many insurers and it may be difficult to know who is in-network and who isn’t.”
In this study, anesthesiologists and pathologists were a source of surprise bills, and they are behind the scenes, he pointed out. “The patient doesn’t select them directly and there is no opportunity to even find out who they are,” said Melnick.
Most patients have no idea that there may be other doctors involved with a colonoscopy, and Melnick highlighted his own recent experience. “I just had a colonoscopy and it never would have occurred to me. It never crossed my mind to even ask who is in network and who isn’t,” he said. “And I’m an expert on this.”
“The health plan could bear some responsibility here,” Melnick commented, although he added that patients need to be informed. Patients who are undergoing an elective procedure should be told that other doctors may be involved, and then to ask if these doctors are in the network. “If enough patients do this, maybe then the gastroenterologist will use people in network,” he commented.
Details of the Surprise Bills
Federal regulations eliminate consumer cost-sharing when screening colonoscopies are performed in-network, but there are no stipulations regarding expenses when out-of-network providers are used, the authors note.
To investigate this issue, the authors used a claims database from a large national insurer and identified patients aged 18 to 64 years who had undergone colonoscopy between 2012 and 2017.
The analysis was limited to cases where both the facility and the endoscopist were in-network, and the colonoscopies were stratified into those with visual inspection only and those during which an intervention was done, such as a biopsy. The primary outcome measure was the prevalence of out-of-network claims when the endoscopist and facility were in-network, and the secondary outcome was the amount of the potential surprise bills, which were calculated as the total out-of network charges less the typical in-network price.
A total of 1,118,769 elective colonoscopies with in-network endoscopists and facilities were identified and of these, 12.1% (n = 135,626) were involved with out-of-network claims. Out-of network anesthesiologists accounted for 64% of cases (median potential surprise bill, $488), while out-of-network pathologists were involved in 40% of cases (median potential surprise bill, $248). The likelihood of receiving an out-of-network claim was significantly higher if an intervention was performed during colonoscopy, as compared with those without intervention (13.9% vs. 8.2%; difference, 5.7%).
If an intervention was performed, 56% of potential surprise bills involved anesthesiologists and 51% pathologists. In cases with visual inspection only, 95% of out-of-network claims involved anesthesiologists.
The authors suggest that measures that can be taken to avoid surprise bills include having endoscopists and hospitals partner with anesthesia and pathology providers who are in-network. Another cost-saving strategy is the use of endoscopist-provided sedation rather than use of deeper anesthesia, and the authors also suggest that not all low-risk polyps need to be sent for pathological evaluation.
“Providers must realize many of our patients are at risk for considerable balance bills, and therefore they should provide resources that can provide reliable estimates for ou-of-pocket costs relevant to site of service,” said lead author James Scheiman, MD, a professor of medicine at the University of Virginia School of Medicine in Charlottesville.
The study was funded by the University of Michigan. Chhabra reports personal fees from Blue Cross Blue Shield of Massachusetts, Inc. Scheiman and Melnick have no disclosures.
Ann Int Med. Published online October 12, 2020. Research Letter