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Insured Patients Are Getting Surprise Bills After Colonoscopies
  • Posted October 16, 2020

Insured Patients Are Getting Surprise Bills After Colonoscopies

Many Americans who get recommended colon cancer screening may end up with "surprise" medical bills, a new study suggests.

Looking at insurance claims for more than 1.1 million elective colonoscopies, researchers found that 12% involved out-of-network charges.

That's concerning, the study authors said, because those patients may well have faced bills averaging $400 for a procedure they thought was covered.

The issue has received much media attention of late. Surprise billing happens when insured people receive treatment from a provider in their health plan's contracted network, but someone on the medical team is not in-network.

The insurance plan may pay part of that provider's charges, but generally not all. So the patient often ends up with an unexpected bill for the rest.

Often, surprise bills are related to elective surgery -- a situation in which patients pick their surgeon and hospital but have no choice about other providers involved in their care. Those providers, such as assistant surgeons, anesthesiologists and radiologists, may be out-of-network, the researchers explained.

But the new study shows the problem extends to screening colonoscopy, a recommended way to catch colon cancer early.

"We want to bring attention to this," said lead researcher Dr. James Scheiman, chief of gastroenterology at University of Virginia Health in Charlottesville. "There really has been no assessment of the scope of the problem."

The concern is that some folks will be deterred from getting colon cancer screening, he said.

Experts recommend that people at average risk of colon cancer begin screening at age 45 or 50. That can be done various ways, and a colonoscopy every 10 years is one option. During the procedure, the doctor can not only detect cancer, but also remove any pre-cancerous growths.

"We know it works," Scheiman said. "We can't let out-of-pocket costs keep people from this potentially life-saving screening."

The findings -- published online Oct. 12 in Annals of Internal Medicine -- are based on claims from a large national health insurance plan. Scheiman's team focused on more than 1.1 million elective colonoscopies where the facility and the doctor performing the procedure were in the health plan's network.

Despite that, one in eight claims included out-of-network charges. That translated to nearly 136,000 colonoscopies for which patients potentially received a surprise bill. (There was no way to determine how many patients actually did, Scheiman said.)

Those out-of-network charges were typically around $1,000. Accounting for the portion the insurer would likely pay, the researchers estimated that the typical surprise bill would be about $400.

Overall, anesthesiologists and pathologists (doctors who study tissue samples) accounted for most out-of-network charges, the investigators found.

And that's no surprise, said Loren Adler, associate director of the USC-Brookings Schaeffer Initiative for Health Policy, in Washington, D.C.

In general, Adler said, surprise bills come from a limited number of specialties -- the providers patients do not choose. Emergency room doctors, anesthesiologists, radiologists and pathologists -- as well as ambulance services -- are the primary sources.

"In my eyes, this is because of a market failure," Adler said. A primary care doctor or surgeon, for instance, has a big incentive to join health plan networks -- to attract patients covered by those plans.

But with certain specialties, the hospital or other workplace determines how many patients a provider sees. Those doctors can remain out-of-network, charge what they want, collect some amount from the insurance company -- and then bill the patient for the balance.

The practice obviously has financial consequences for patients. But it's also costly to anyone with private health insurance, Adler said. Plans raise their monthly premiums to help cover the costs of out-of-network providers.

That's partly because health plans do sometimes pay the full out-of-network charge. It's also because those same specialists command higher in-network prices compared to other specialties, he noted.

Many hospitals have moved to address the problem, requiring doctors to join their center's insurance networks, Adler said.

A broad solution would be legislation to cap out-of-network charges, he added. Some states have passed laws to at least partially protect patients from surprise bills, but federal action has stalled.

More information

USC-Brookings Schaeffer has an overview of surprise billing.

SOURCES: James Scheiman, MD, chief, gastroenterology and hepatology, University of Virginia Health, Charlottesville, Va.; Loren Adler, MS, associate director, USC-Brookings Schaeffer Initiative for Health Policy, Washington, D.C.; Annals of Internal Medicine, Oct. 12, 2020, online
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