Scientific Article| Volume 47, ISSUE 12, P1230.e1-1230.e17, December 2022

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Surprise Out-of-Network Bills for Hand and Upper Extremity Trauma Patients

Published:November 08, 2021DOI:


      Patients may receive surprise out-of-network bills even when they present to in-network facilities. Surprise bills are common following emergency care. We sought to characterize and determine risk factors for surprise billing in hand and upper extremity trauma patients in the emergency department (ED).


      We used IBM MarketScan data to evaluate hand and upper extremity trauma patients who received care in the ED from 2010 to 2017. Our primary outcome was the surprise billing incidence, defined as encounters in in-network EDs with out-of-network claims. We used descriptive and bivariate analyses to characterize surprise billing and used multivariable logistic regression to evaluate independent factors associated with surprise billing.


      Of 710,974 ED encounters, 97,667 (14%) involved surprise billing. The incidence decreased from 26% in 2010 to 11% in 2017. Mean coinsurance payments were higher for surprise billing encounters and had double the growth from 2010 to 2017 compared to those without surprise billing. Receiving care from different provider types—especially therapists, radiologists, and pathologists, as well as hand surgeons—was associated with significantly higher odds of surprise billing. Transfer to another facility was not significantly associated with surprise billing.


      Although the incidence of surprise billing decreased, more than 10% of patients treated in an ED for hand trauma remain at risk. Coinsurance for surprise billing encounters increased by twice as much as encounters without surprise billing. Patients requiring services from therapists, radiologists, pathologists, and hand surgeons were at greater risk for surprise bills. The federal No Surprises Act, passed in 2020, targets surprise billing and may help address some of these issues.

      Clinical relevance

      Many hand and upper extremity patients requiring ED care receive surprise bills from various sources that result in higher out-of-pocket costs.

      Key words

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        • Haeder S.F.
        • Weimer D.L.
        • Mukamel D.B.
        Surprise billing: no surprise in view of network complexity.
        Health Aff. 2019; 38: 1918-1926
        • Garmon C.
        • Chartock B.
        One in five inpatient emergency department cases may lead to surprise bills.
        Health Aff (Millwood). 2017; 36: 177-181
        • Long C.
        • Cho B.H.
        • Giladi A.M.
        Understanding surprise out-of-network billing in hand and upper extremity care.
        J Hand Surg Am. 2021; 46: 236-240
        • Cooper Z.
        • Scott Morton F.
        Out-of-network emergency-physician bills–an unwelcome surprise.
        N Engl J Med. 2016; 375: 1915-1918
        • Dekhne M.S.
        • Nuliyalu U.
        • Schoenfeld A.J.
        • Dimick J.B.
        • Chhabra K.R.
        “Surprise” out-of-network billing in orthopedic surgery: charges from surprising sources.
        Ann Surg. 2020; 271: e116-e118
        • Chhabra K.R.
        • Sheetz K.H.
        • Nuliyalu U.
        • Dekhne M.S.
        • Ryan A.M.
        • Dimick J.B.
        Out-of-network bills for privately insured patients undergoing elective surgery with in-network primary surgeons and facilities.
        JAMA. 2020; 323: 538-547
        • Sun E.C.
        • Mello M.M.
        • Moshfegh J.
        • Baker L.C.
        Assessment of out-of-network billing for privately insured patients receiving care in in-network hospitals.
        JAMA Intern Med. 2019; 179: 1543-1550
        • Ootes D.
        • Lambers K.T.
        • Ring D.C.
        The epidemiology of upper extremity injuries presenting to the emergency department in the United States.
        Hand (N Y). 2012; 7: 18-22
        • Maroukis B.L.
        • Chung K.C.
        • MacEachern M.
        • Mahmoudi E.
        Hand trauma care in the United States: a literature review.
        Plast Reconstr Surg. 2016; 137: 100e-111e
        • Friedrich J.B.
        • Poppler L.H.
        • Mack C.D.
        • Rivara F.P.
        • Levin L.S.
        • Klein M.B.
        Epidemiology of upper extremity replantation surgery in the United States.
        J Hand Surg Am. 2011; 36: 1835-1840
        • Billig J.I.
        • Nasser J.S.
        • Cho H.E.
        • Chou C.H.
        • Chung K.C.
        Association of interfacility transfer and patient and hospital characteristics with thumb replantation after traumatic amputation.
        JAMA Netw Open. 2021; 4e2036297
        • American Society for Surgery of the Hand
        ASSH/ACS National Hand Trauma Center Network.
        (Accessed June 4, 2021.)
        • IBM Watson Health
        IBM MarketScan Research Databases User Guide: Commercial Claims and Encounters Database and Medicare Supplemental and Coordination of Benefits Database.
        IBM Watson Health, 2017
        • Jarque C.M.
        • Bera A.K.
        Efficient tests for normality, homoscedasticity, and serial independence of regression residuals.
        Econ Lett. 1980; 6: 255-259
        • Cooper Z.
        • Nguyen H.
        • Shekita N.
        • Morton F.S.
        Out-of-network billing and negotiated payments for hospital-based physicians.
        Health Aff (Millwood). 2020; 39: 24-32
        • Board of Governors of the Federal Reserve System
        Report on the Economic Well-Being of U.S. Households in 2015: Economic Preparedness and Emergency Savings.
        Board of Governors of the Federal Reserve System, 2016
        • The Commonwealth Fund
        Balance billing by health care providers: assessing consumer protections across states.
        (Accessed June 5, 2021.)
        • The Commonwealth Fund
        State balance-billing protections.
        (Accessed June 5, 2021.)
        • Hoadley J.
        • Kona M.
        • Lucia K.
        State balance-billing protections.
        (Accessed May 15, 2020.)
        • Chhabra K.R.
        • Fuse Brown E.
        • Ryan A.M.
        No more surprises–new legislation on out-of-network billing.
        N Engl J Med. 2021; 384: 1381-1383
        • Kyanko K.A.
        • Pong D.D.
        • Bahan K.
        • Curry L.A.
        Patient experiences with involuntary out-of-network charges.
        Health Serv Res. 2013; 48: 1704-1718
        • Shen W.S.
        Balance Billing: Current Legal Landscape and Proposed Federal Solutions.
        Congressional Research Service, 2019
        • Boccuti C.
        Paying a visit to the doctor: current financial protections for Medicare patients when receiving physician services. Kaiser Family Foundation.
        (Accessed May 11, 2020.)
        • Song Z.
        • Johnson W.
        • Kennedy K.
        • Biniek J.F.
        • Wallace J.
        Out-of-network spending mostly declined in privately insured populations with a few notable exceptions from 2008 to 2016.
        Health Aff (Millwood). 2020; 39: 1032-1041