Advertisement

Prevalence, Burden, and Sources of Out-of-Network Billing in Elective Hand Surgery: A National Claims Database Analysis

Published:August 01, 2022DOI:https://doi.org/10.1016/j.jhsa.2022.06.002

      Purpose

      Surprise out-of-network (OON) bills can represent a considerable cost burden on patients. However, OON billing remains underexplored in elective, outpatient surgery procedures, which have greater latitude for patient choice. We aimed to answer the following questions: (1) What is the prevalence and magnitude of OON charges in hand surgery? (2) What are the sources of OON charges? and (3) What factors are associated with OON charges?

      Methods

      We analyzed patient-level data from the Clinformatics Data Mart database. We identified patients undergoing carpal tunnel release, trigger finger release, wrist ganglion removal, de Quervain release, limited palmar fasciectomy, or thumb carpometacarpal arthroplasty at in-network facilities with an in-network primary surgeon. The primary outcome was the proportion of surgical episodes with at least 1 OON charge. Secondary outcomes included the magnitude of potential balance bills (portion of OON bill exclusive of the standardized payment and expected patient cost-sharing), sources of OON charges, and factors associated with OON charges.

      Results

      Of 112,211 elective hand surgery episodes, 8% (9,158) had at least 1 OON charge. OON charges ranged from $1,154 (95% confidence interval, $1,018–$1,289) for wrist ganglion removal to $3,162 (95% confidence interval, $2,902–$3,423) for thumb carpometacarpal arthroplasty. In episodes with OON charges, the major sources of OON charges were anesthesiologists (75% of episodes), durable medical equipment (10% of episodes), and pathologists (9% of episodes). Site of service, geographic region, and health exchange-purchased plans were highly associated with OON charges.

      Conclusions

      Out-of-network billing can represent a substantial cost burden to patients and should be considered in perioperative decision-making in elective hand surgery.

      Clinical relevance

      Understanding the potential costs related to OON services during a surgical episode, and its drivers, allows surgeons to consider detailed cost discussions during perioperative decision making.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of Hand Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Cooper Z.
        • Scott Morton F.
        Out-of-network emergency-physician bills—an unwelcome surprise.
        N Engl J Med. 2016; 375: 1915-1918
        • Hall M.A.
        • Adler L.
        • Ginsburg P.B.
        • Trish E.
        Reducing unfair out-of-network billing—integrated approaches to protecting patients.
        N Engl J Med. 2019; 380: 610-612
        • 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
        • McKnight R.
        Medicare balance billing restrictions: impacts on physicians and beneficiaries.
        J Health Econ. 2007; 26: 326-341
        • Schechter R.M.
        • Sklar D.E.
        No surprises act and the provider/patient/payor dynamic backdrop.
        Am Bankruptcy Inst J. 2022; 41: 8-55
        • 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
        • 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
        • 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
        • Zhuang T.
        • Eppler S.L.
        • Shapiro L.M.
        • Roe A.K.
        • Yao J.
        • Kamal R.N.
        Financial distress is associated with delay in seeking care for hand conditions.
        Hand (N Y). 2021; 16: 511-518
        • Mertz K.
        • Eppler S.L.
        • Thomas K.
        • et al.
        The association of financial distress with disability in orthopaedic surgery.
        J Am Acad Orthop Surg. 2019; 27: e522-e528
        • 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
        • Pourhoseingholi M.A.
        • Vahedi M.
        • Rahimzadeh M.
        Sample size calculation in medical studies.
        Gastroenterol Hepatol Bed Bench. 2013; 6: 14-17
        • Norton E.C.
        • Dowd B.E.
        • Maciejewski M.L.
        Marginal effects—quantifying the effect of changes in risk factors in logistic regression models.
        JAMA. 2019; 321: 1304-1305
        • Bosco J.A.
        Subject: upcoming rulemaking on No Surprises Act (2020).
        • Barnes J.I.
        • Paci G.
        • Zhuang T.
        • Baker L.C.
        • Asch S.M.
        • Kamal R.N.
        Cost-effectiveness of open versus endoscopic carpal tunnel release.
        J Bone Joint Surg Am. 2021; 103: 343-355
        • Kazmers N.H.
        • Presson A.P.
        • Xu Y.
        • Howenstein A.
        • Tyser A.R.
        Cost implications of varying the surgical technique, surgical setting, and anesthesia type for carpal tunnel release surgery.
        J Hand Surg Am. 2018; 43: 971-977.e1
        • Chatterjee A.
        • McCarthy J.E.
        • Montagne S.A.
        • Leong K.
        • Kerrigan C.L.
        A cost, profit, and efficiency analysis of performing carpal tunnel surgery in the operating room versus the clinic setting in the United States.
        Ann Plast Surg. 2011; 66: 245-248
        • Rhee P.C.
        • Fischer M.M.
        • Rhee L.S.
        • McMillan H.
        • Johnson A.E.
        Cost savings and patient experiences of a clinic-based, wide-awake hand surgery program at a military medical center: a critical analysis of the first 100 procedures.
        J Hand Surg Am. 2017; 42: e139-e147
        • White M.
        • Parikh H.R.
        • Wise K.L.
        • Vang S.
        • Ward C.M.
        • Cunningham B.P.
        Cost savings of carpal tunnel release performed in-clinic compared to an ambulatory surgery center: time-driven activity-based-costing.
        Hand (N Y). 2021; 16: 746-752
        • Jagodzinski N.A.
        • Ibish S.
        • Furniss D.
        Surgical site infection after hand surgery outside the operating theatre: a systematic review.
        J Hand Surg Eur Vol. 2017; 42: 289-294
        • LeBlanc M.R.
        • Lalonde D.H.
        • Thoma A.
        • et al.
        Is main operating room sterility really necessary in carpal tunnel surgery? A Multicenter prospective study of minor procedure room field sterility surgery.
        Hand (N Y). 2011; 6: 60-63
        • Grandizio L.C.
        • Graham J.
        • Klena J.C.
        Current trends in WALANT surgery: a survey of American Society for Surgery of the Hand Members.
        J Hand Surg Glob Online. 2020; 2: 186-190
        • Tan E.
        • Bamberger H.B.
        • Saucedo J.
        Incorporating office-based surgery into your practice with WALANT.
        J Hand Surg Am. 2020; 45: 977-981
        • Van Demark R.E.
        • Smith V.J.S.
        • Fiegen A.
        Lean and green hand surgery.
        J Hand Surg Am. 2018; 43: 179-181
        • Amanatullah D.F.
        • Murasko M.J.
        • Chona D.V.
        • Crijns T.J.
        • Ring D.
        • Kamal R.N.
        Financial distress and discussing the cost of total joint arthroplasty.
        J Arthroplasty. 2018; 33: 3394-3397
        • Kircher S.M.
        • Yarber J.
        • Rutsohn J.
        • et al.
        Piloting a financial counseling intervention for patients with cancer receiving chemotherapy.
        J Oncol Pract. 2019; 15: e202-e210
        • LePere D.B.
        • Bickham R.S.
        • Ingraham J.M.
        Utility of routine pathologic specimens in ganglion wrist excisions.
        Plast Reconstr Surg Glob Open. 2020; 8 (103–103)
        • Guitton T.G.
        • van Leerdam R.H.
        • Ring D.
        Necessity of routine pathological examination after surgical excision of wrist ganglions.
        J Hand Surg Am. 2010; 35: 905-908
        • Pugely A.J.
        • Martin C.T.
        • Harwood J.
        • Ong K.L.
        • Bozic K.J.
        • Callaghan J.J.
        Database and registry research in orthopaedic surgery: part I claims-based data.
        J Bone Joint Surg Am. 2015; 97: 1278-1287