“Surprise” Out-of-network Billing in Orthopedic Surgery

Dekhne, Mihir S; Nuliyalu, Ushapoorna; Schoenfeld, Andrew J.; Dimick, Justin B.; Chhabra, Karan R.

doi:10.1097/sla.0000000000003825

Cited by 25 publications

(25 citation statements)

References 3 publications

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“…These findings may have implications for surprise billing for patients undergoing spine surgery at ASCs. Our results are in line with a study by Dekhne et al 5 which found that for lumbar discectomies, IONM was the most common source of a surprise bill to the patient. These unexpected costs may result in financial stress to the patient and reluctance of future treatment.…”

Section: Discussionsupporting

confidence: 93%

Characteristics of Spine Surgery Performed at Ambulatory Surgical Centers

Durand

Musharbash

Ortiz-Babilonia

et al. 2022

Spine

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uring the past few decades, outpatient surgeries dramatically increased in number, and now represent the majority of operations performed in the United States. 1 Ambulatory surgery centers (ASCs) have grown in popularity in recent years to meet the growing demand. 2 Spinal surgeries such as anterior cervical discectomies, as well as lumbar microdiscectomies and laminectomies, can be safely performed in an ASC. 3 The aim of this study was to investigate trends in a patient, surgical, and billing characteristics of spinal surgeries performed in the ASC in the United States, including the utilization of intraoperative neuromonitoring. We focused on the commercially insured population as most spinal surgeries continue to remain on the Medicare in-patient only lists. MATERIALS AND METHODS Data SourcesThis was a retrospective cohort study using the IBM Truven MarketScan Commercial Database. This database compiles insurance data from > 20 billion service records.

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Section: Discussionsupporting

confidence: 93%

Characteristics of Spine Surgery Performed at Ambulatory Surgical Centers

Durand

Musharbash

Ortiz-Babilonia

et al. 2022

Spine

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“…This coincides with a previous report that nearly 1 in 6 patients undergoing elective orthopedic surgery is potentially at risk for a surprise bill. 28 , 29 It is important to understand these finance-related issues bscause they are a common source of complaints for orthopedic surgeons. A study of 1,077 patients involved in orthopedic sports medicine found that being an in-network provider was, predictably, 1 of the most important factors for patients when choosing an orthopedic sports medicine physician.…”

Section: Discussionmentioning

confidence: 99%

The Majority of Complaints About Orthopedic Sports Surgeons on Yelp Are Nonclinical

Pollock

Arthur

Smith

et al. 2021

Arthroscopy, Sports Medicine, and Rehabilitation

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Purpose: To examine and characterize extremely negative Yelp reviews of orthopedic sports surgeons in the United States. Methods: A search for reviews was performed using the keywords "Orthopedic Sports Medicine" on Yelp.com for 8 major metropolitan areas. Single-star reviews were isolated for analysis, and individual complaints were then categorized as clinical or nonclinical. The reviews were classified as surgical or nonsurgical. Results: A total of 11,033 reviews were surveyed. Of these, 1,045 (9.5%) were identified as 1-star, and 289 were ultimately included in the study. These reviews encompassed 566 total complaints, 133 (23%) of which were clinical, and 433 (77%) of which were nonclinical in nature. The most common clinical complaints concerned complications (32 complaints; 6%), misdiagnosis (29 complaints; 5%), and uncontrolled pain (21 complaints; 4%). The most common nonclinical complaints concerned physicians' bedside manner (120 complaints; 21%), unprofessional staff (98 complaints; 17%), and finances (78 complaints; 14%). Patients who had undergone surgery wrote 47 reviews that resulted in 114 complaints (20.5% of total complaints), whereas nonsurgical patients were responsible for 242 reviews and a total of 452 complaints (81.3% of total complaints). The difference in the number of complaints by patients after surgery and patients without surgery was statistically significant (P < 0.05) for all categories except for uncontrolled pain, delay in care, bedside manner of midlevel staff, and facilities. Conclusion: Our study of extremely negative Yelp reviews found that 77% of negative complaints were nonclinical in nature. The most common clinical complaints were complications, misdiagnoses and uncontrolled pain. Only 16% of 1-star reviews were from surgical patients. Clinical Relevance: Patients use online review platforms when choosing surgeons. A comprehensive understanding of factors affecting patient satisfaction and dissatisfaction is needed. The results of our study could be used to guide future quality-improvement measures and to assist surgeons in maintaining favorable online reputations.

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“…1 This high incidence is likely due to multiple factors, such as the large number of emergency plastic surgery procedures (ie, laceration repair), utilization of air and ground ambulance transport for trauma patients, and the overall interdisciplinary quality of plastic surgery care. 3 Many plastic surgeons also elect to not participate in health plans and do not accept insurance. In all these scenarios, patients are at the high risk of unknowingly receiving an out-of-network service or receiving care from an out-of-network plastic surgeon or ancillary provider.…”

Section: The No Surprises Act In Plastic and Reconstructive Surgerymentioning

confidence: 99%

“…Anesthesia, radiology, and emergency medicine physicians have been cited as some of the most frequent providers to bill patients surprise charges. 1,3,5 This is because many in-network hospitals contract out these services to out-of-network groups. For example, a study in 2012 demonstrated that up to 23.5% of emergency medicine physicians are independent contractors.…”

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confidence: 99%

“…

Surprise bills are frequently associated with air and ground ambulance transport, ED visits, and emergency surgery. [2][3][4] In these settings, patients are often unable to choose their providers, and thus are at risk for receiving out-of-network care, even at an in-network facility. Anesthesia, radiology, and emergency medicine physicians have been cited as some of the most frequent providers to bill patients surprise charges.

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confidence: 99%

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The No Surprises Act: What Do Plastic Surgeons Need to Know?

Seitz

Nicksic

Rao

2022

Plastic and Reconstructive Surgery - Global Open

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Background: Out-of-network, or “surprise” bills, have grown common in recent years and have raised substantial concern for patients. Congress recently enacted the No Surprises Act, effective on January 1, 2022, ending the majority of out-of-network bills for privately insured patients. The aim of this review is to briefly summarize the history of surprise billing, describe the regulations of the No Surprises Act, and examine the impact this legislation will have on the field of plastic surgery. Methods: A PubMed and Google Scholar literature search was conducted on out-of-network billing, or surprise bills, and the No Surprises Act. Media outlets, governmental agencies, and local and national medical organizations were additionally queried for surprise billing and the No Surprises Act. Results: Under the No Surprises Act, privately insured patients are protected from surprise medical bills in emergency and nonemergency settings, and uninsured or self-pay patients must be provided a good faith estimate of service fees before receiving nonemergent care. Plastic surgeons may consent patients to receive out-of-network bills if consent is obtained at least 72 hours before rendering a nonemergency service. Despite these patient protections, this act may influence plastic surgeons’ reimbursement rates and incentivize surgeons to alter their network status. Conclusions: The No Surprises Act provides significant protections for patients. However, it may have adverse effects for plastic surgeons. Plastic surgeons will only get paid in-network fees while providing care to patients unless consent is properly obtained in a nonemergent setting.

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“Surprise” Out-of-network Billing in Orthopedic Surgery

Cited by 25 publications

References 3 publications

Characteristics of Spine Surgery Performed at Ambulatory Surgical Centers

Characteristics of Spine Surgery Performed at Ambulatory Surgical Centers

The Majority of Complaints About Orthopedic Sports Surgeons on Yelp Are Nonclinical

The No Surprises Act: What Do Plastic Surgeons Need to Know?

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