Surprise Billing Research Articles

No Surprises Act independent dispute resolution outcomes for emergency services.

The No Surprises Act banned surprise billing and established a final-offer arbitration system, independent dispute resolution (IDR), to resolve disagreements between health plans and providers. One factor that arbiters must consider in the IDR process is the qualifying payment amount (QPA), the median contracted rate for the same or similar service in the same market as computed by health plans. We analyzed public IDR data from 2023 for the most common disputed professional service: evaluation and management of a moderate to severe emergency medicine visit. Providers won 86% of cases, with mean decisions 2.7 times the QPA. Private equity-backed providers won more often and higher monetary awards than other providers. The mean QPA was 2.4 times Medicare payments. Disputes were dominated by a small group of health plans and providers, so payments may not reflect the overall market for emergency services.

The impacts of New York's balance billing regulation on ground ambulance pricing.

To examine the effects of New York's surprise billing regulations on price changes by emergency ground ambulance service providers. We exploited a natural experiment using a difference-in-differences design with randomization inference (RI) to examine the effects of New York state regulations on the prices of emergency ground ambulances, analyzing 2012-2019 commercial claims data. In March 2015, New York implemented a law protecting patients from surprise out-of-network (OON) balance bills, including ground ambulance services. New York's policy tied OON ground ambulance reimbursements to usual, customary, and reasonable rates that typically reflect charges. The control group consisted of similar states that never enacted surprise billing laws. Although self-funded plans are exempted from state laws, we also examined for spillover effects on self-funded plans. Multi-payer national commercial plan claims data were used. The study sample was selected by isolating claims involving an emergency ground ambulance activation code. The event study findings indicated that New York's law led to a continuous increase in prices, relative to controls. The law's implementation was associated with an overall emergency ground ambulance price increase of 13 percentage points (RI p-value: 0.07). We observed a 21-percentage-point increase in in-network prices (RI p-value: 0.07) and a 19-percentage-point increase in OON prices (RI p-value: 0.07), relative to controls, for fully insured health plans. Similar changes in overall prices and in in-network prices were observed in self-insured plans. Last, our study did not find statistically significant evidence of changes in out-of-pocket cost-sharing amounts under New York's regulation. Balance billing laws based on charges can lead to price increases for emergency ground ambulance services. Legislation intended to inoculate patients from these surprise billings for ground ambulance transportation may have unintended consequences for costs of care. Emergency ground ambulances are a major source of surprise billing. The federal No Surprises Act of 2020 excluded emergency ground ambulance services. Some states have regulations that prohibit out-of-network balance bills for ground ambulance services. The study provides the first empirical evidence on the potential impacts of regulations on price changes among emergency ground ambulance providers. The study offers evidence of state policies' effects on fully insured plans and potential spillover effects on self-funded plans. Experiences from New York's state ambulance out-of-network billing regulation indicate that tying reimbursement policies to charges may have the unintended consequences of increasing health care costs.

The Controversy over Price Transparency: Patients and Plastic Surgeons Disagree.

The No Surprises Act (NSA) went into effect on January 1, 2022. This federal law is designed to minimize surprise bills for emergency care, out of network (OON) care, and care for uninsured or self-pay individuals. To achieve these goals, the NSA relies heavily on physicians providing cost estimates to patients prior to administering care. Because healthcare is often price-opaque, this study was conducted to assess physician and patient attitudes toward price transparency in plastic surgery and aesthetic/self-pay medicine. Two cohorts of providers received a survey asking whether and how their practice offers pricing information prior to a consultation and their views regarding the NSA. Patients who had previously used an online price estimator tool also received a survey regarding their experience and accuracy of estimates received online. Most surveyed providers do not share the costs of their services online, whereas patients had a positive experience when receiving estimates of medical services before consultation. Although many providers cited the inaccuracy of price estimator tools as a reason not to incorporate them into their website, most patients reported that their final cost of service was close to (or even less than) the estimate received online prior to the consultation. This study suggests that price transparency is a patient satisfier. Therefore, plastic surgeons should exercise price transparency to be compliant with federal law and to gain a competitive advantage in the market, as the decision to implement price transparency can be mutually beneficial to patients and providers.

The impact of surprise billing laws on emergency services.

Numerous states implemented laws to protect emergency patients from surprise out-of-network medical bills. We investigated the effects of the state laws on emergency clinician reimbursements, charges, network participation, and potential surprise billing episodes. We did not find consistent evidence of effects on prices or charges. However, the state laws resulted in increased network participation and a reduction in potential surprise billing episodes. Our results suggest that the federal No Surprises Act, which is similar to many of the state laws, is unlikely to lead to price increases, but may benefit patients through increased provider network participation and alignment.

The impact of health policy on surgical and trauma patients: Three key examples

Health policy impacts the way surgical and trauma patients access, recover from, and pay for the medical care we deliver. In this editorial, we highlight 3 major policy directives that have or will affect millions of surgical and injured patients—Medicaid expansion, surprise billing, and housing in previously redlined districts. In doing so, we aim to elucidate the mechanisms by which health policies impact our patients and encourage participation and inquiry among surgeons when new health policies are being proposed at a national, state, or local level.

Surprise Billing in Foot and Ankle Surgery and Its Effect on Patient Satisfaction

Introduction/Purpose: Patients undergoing foot and ankle surgery may find themselves facing unexpected medical bills. This is known as surprise billing and has caused financial hardship for many patients, prompting policymakers to pass the “No Surprise Act”. The purpose of this study was to determine the incidence of surprise bills in patient undergoing foot and ankle surgery and the effect of surprise billing on patient satisfaction. Methods: This was a retrospective study of patients who underwent a foot and ankle surgery from May 2021 to November 2022 at a large multi-state institution. Patients completed a questionnaire regarding the incidence of surprise bills following their surgery, the details regarding those bills, and how those bills affected the surgical satisfaction. Results: Of the 771 responses, 23% of participants received at least one surprise bill following their foot and ankle procedure, with 39% of these bills being greater than $1000. The most common surprise bill came from the surgical facility (46%) followed by anesthesia (42%). Furthermore, the incidence of surprise billing before and after the implementation of the “No Surprise Act” on January 1st, 2022 was not found be significantly different (p=0.134). Patients who received surprise bills reported being significantly less satisfied with their surgery (p < 0.001) and felt their billing experience affected their surgical satisfaction. Conclusion: Despite recent legislative efforts, surprise billing in foot and ankle surgery is common and can negatively affect patient surgical satisfaction. Although surgeons may be unable to limit the amount of bills patients receive postoperatively, increased communication and education regarding the perioperative billing process may prove to be beneficial for both patient satisfaction and the doctor-patient relationship.

Comprehending Qualifying Payment Amount (QPA) and the No Surprise Act in Healthcare

Purpose: This article investigates the No Surprise Act, a pivotal piece of legislation designed to protect consumers from unexpected out-of-network healthcare charges, emphasizing the Qualifying Payment Amount (QPA) mechanism.
 Methodology: Through a comprehensive literature review, analysis of legislative texts, and examination of case studies, this study elucidates the Act's origins, objectives, and operational framework of the QPA. It also explores the challenges of implementing the Act, its impact on various stakeholders (patients, healthcare providers, and insurers), and the broader implications for the U.S. healthcare system. Despite its intentions to curb surprise billing practices, the No Surprise Act and its QPA component face several implementation challenges, including administrative burdens, disputes over payment calculations, and unintended consequences on insurance premiums and healthcare market dynamics. This article leverages recent data, expert opinions, and comparative analysis with other healthcare models to provide a nuanced evaluation of the Act's effectiveness and areas for improvement.
 Findings: The findings suggest that while the No Surprise Act represents a significant step forward in patient financial protection, ongoing adjustments and policy refinements are essential for achieving its intended outcomes without compromising the sustainability of healthcare providers and insurers.
 Unique Contributor to Theory, Policy and Practice: Study and policy recommendations aims to contribute to the ongoing dialogue and efforts to enhance patient protection and healthcare affordability in the U.S., ensuring that the No Surprise Act lives up to its promise and potential..

Surprise billing in intensive care unit (ICU) hospitalizations.

Intensive care unit (ICU) care is expensive for patients and providers, and utilization and spending on ICU resources have increased. The No Surprises Act, passed in 2022, specifically prohibits balance billing by ICU specialists (intensivists) for emergency and most non-emergency care. The potential economic impact of this remains unclear, given few data exist on the magnitude of balance billing in the ICU. Using the MarketScan Commercial (IBM) database, we studied hospitalizations in which ICU care was provided ("ICU hospitalizations") between 2010 and 2019. Hospitalizations were characterized as fully in-network, fully out-of-network, or "mixed" (contained both in- and out-of-network services). The share of "mixed" hospitalizations among all ICU hospitalizations rose from 26% to 33% over the study period. Over half of these mixed hospitalizations contained out-of-network services specifically delivered within the ICU. Total hospitalization spending averaged $81 047, with ICU spending averaging $15 799. On average, 11% of ICU spending within these hospitalizations was out-of-network. Patients were plausibly balance-billed in approximately one-third of ICU hospitalizations, for thousands of dollars per hospitalization. Given that the No Surprises Act prevents this type of balance billing, the portended revenue loss may lead to changes in provider negotiations with insurers concerning network status and prices, which could affect the care patients receive.

Site of Ambulance Origination and Billing for Out-of-Network Services

The No Surprises Act implemented in 2022 aims to protect patients from surprise out-of-network (OON) bills, but it does not include ground ambulance services. Understanding ground ambulance OON and balance billing patterns from previous years could guide legislation aimed to protect patients following ground ambulance use. To characterize OON billing from ground ambulance services by evaluating whether OON billing risk differs by the site of ambulance origination (home, hospital, nonhospital medical facility, or scene of incident). Cross-sectional study of the Merative MarketScan dataset between January 1, 2015, and December 31, 2020, using claims-based data from employer-based private health insurance plans in the US. Participants included patients who utilized ground ambulances during the study period. Data were analyzed from June to December 2023. Medical encounter requiring ground ambulance transportation. Ground ambulance OON billing prevalence was calcuated. Linear probability models adjusted for state-level mixed effects were fit to evaluate OON billing probability across ambulance origins. Secondary outcomes included the allowed payment, patient cost-sharing amounts, and potential balance bills for OON ambulances. Among 2 031 937 ground ambulance services (1 375 977 unique patients) meeting the inclusion and exclusion criteria, 1 072 791 (52.8%) rides transported men, and the mean (SD) patient age was 41 (18) years. Of all services, 1 113 676 (54.8%) were billed OON. OON billing probabilities for ambulances originating from home or scene were higher by 12.0 percentage points (PP) (95% CI, 11.8-12.2 PP; P < .001 for home; 95% CI, 11.7-12.2 PP; P < .001 for scene) vs those originating from hospitals. Mean (SD) total financial burden, including cost-sharing and potential balance bills per ambulance service, was $434.70 ($415.99) per service billed OON vs $132.21 ($244.92) per service billed in-network. In this cross-sectional study of over 2 million ground ambulance services, ambulances originating from home, the scene of an incident, and nonhospital medical facilities were more likely to result in OON bills. Legislation is needed to protect patients from surprise billing following use of ground ambulances, more than half of which resulted in OON billing. Future legislation should at minimum offer protections for these subsets of patients often calling for an ambulance in urgent or emergent situations.

Surprise Billing Is Common in Total Joint Arthroplasty and Negatively Impacts Patient Satisfaction.

Patients undergoing total joint arthroplasty (TJA) may receive unexpected medical bills. Such "surprise" bills may cause financial hardship for patients, which prompted policymakers to pass the No Surprises Act. The purpose of this study was to determine the incidence of surprise bills for patients undergoing TJA and the effect of surprise billing on patient satisfaction. This was a retrospective study of patients who underwent a primary total hip arthroplasty (THA) or total knee arthroplasty (TKA) at a large multi-state institution. Patients completed a questionnaire regarding the incidence of surprise bills after their surgery, details of those bills, and how the bills affected their surgical satisfaction. Independent predictors for receiving a surprise bill were assessed through a multivariate regression analysis. Twelve percent of participants received at least one surprise bill after their TJA. The most common surprise bill came from the surgical facility (48%), followed by anesthesia (36%). Multivariate logistic regression analysis identified older age and Black race to be independent predictors of surprise billing. Furthermore, surgery occurring after the No Surprises Act bill enforcement on January 1, 2022, was found to increase a patient's likelihood of receiving a surprise bill (P=.039, effect size=0.18). Patients who received a surprise bill reported being significantly less satisfied with their surgery (P=.002, effect size=0.45). Forty-nine percent of patients with a surprise bill felt their billing negatively affected their surgical satisfaction. Surprise billing continues to occur after TJA and can negatively affect patient satisfaction. Although surgeons may be unable to limit the amount of bills patients receive postoperatively, increased communication and education regarding the perioperative billing process may prove to be beneficial for both patient satisfaction and the physician-patient relationship. [Orthopedics. 2024;47(5):283-288.].

Radiologists’ Out-of-Network Billing Trends, 2007 to 2021

PurposeGiven the financial hardships of surprise billing for patients, the aim of this study was to assess the degree to which radiologists effectively participate in commercial insurance networks by examining the trend in the share of radiologists’ imaging claims that are out of network (OON). MethodsA retrospective study over a 15-year period (2007-2021) was conducted using claims from Optum’s deidentified Clinformatics Data Mart Database to assess the share of radiologists’ imaging claims that are OON. Radiologists’ annual OON rate was assessed overall as well as for claims associated with inpatient stays and emergency department (ED) visits. Rates were assessed for all imaging studies as well as by modality. Linear regression was conducted to assess OON rate time trends. ResultsFrom 2007 to 2021, 5,039,142 of radiologists’ imaging claims (6.3%) were OON. This rate declined from 12.6% in 2007 to 1.1% in 2021. Over the study period, the OON rate was 5.0% during an inpatient stay and 2.1% on the same day as an ED visit that did not lead to an inpatient admission. The linear trend in the overall OON rate declined 0.74 percentage points annually (95% confidence interval [CI], −0.90 to −0.58 percentage points) over the study period. Likewise, the annual declines were 0.54 percentage points (95% CI, −0.71 to −0.36) and 0.26 percentage points (95% CI, −0.33 to −0.20 percentage points) for imaging claims associated with inpatient stays and ED visits, respectively. ConclusionsRadiologists’ imaging claims that are OON has significantly declined from 2007 to a minimal level in 2021. This may indicate effective negotiations between radiologists and commercial payers and new state-level surprise billing laws.

Surprise Billing in Elective Shoulder Surgery and Its Effect on Patient Satisfaction.

Patients often receive multiple bills following surgery, which may come as a surprise to them if they are not appropriately informed or educated prior to surgery. The purpose of this study was to identify whether surprise billing occurs following shoulder rotator cuff repair and its effect on patient satisfaction. The study surveyed adult patients who underwent elective rotator cuff repair from January 2020 to October 2021. Patients were asked if they received unexpected bills after their surgery, as well as about details regarding those bills. Additionally, patients were asked about their medical insurance carrier, knowledge of the billing process prior to surgery, and how they felt the process could be improved. Finally, patients were asked how these bills and the overall billing process affected their surgical satisfaction. Of the 158 responses, 25% of the patients stated they received at least one surprise bill following their rotator cuff surgery, with 57% of these bills being greater than $1000. Patients who received surprise bills reported being significantly less satisfied with their surgery (P<.001) and felt their billing experience affected their surgical satisfaction (64% vs 9%, P<.001). One in 4 patients undergoing elective rotator cuff repair received a surprise bill following surgery. These bills were monetarily substantial and significantly affected surgical satisfaction. Although surgeons may be unable to limit the amount of bills patients receive postoperatively, increased communication and education regarding the perioperative billing process may prove to be beneficial for both patient satisfaction and the physician-patient relationship. [Orthopedics. 2024;47(2):123-127.].

Private Equity, Value-Based Payments, and Hollow Promises

As private equity (PE) investors have moved into nearly every sector of the health care system, there is growing debate about the financial industry’s role and its impact. In recent years, a number of media stories have exposed seriously concerning behavior of PE-owned health care facilities and companies (O’Grady, 2022; Pomorski, 2021; Sanger-Katz et al., 2019). Critics also point to recent empirical studies documenting rising prices and reductions in quality under PE-backed healthcare companies. For example, a 2021 report documents how PE-backed mergers and acquisitions have contributed to the stark rise in consolidation and increasing prices, especially in the last decade (Scheffler et al., 2021). Evidence documenting reductions in quality-of-care point to PE-backed nursing homes (Gupta et al., 2021), physician management firms related to surprise billing (Cooper et al., 2018), and PE-backed hospitals (Bruch et al., 2021). This is likely because PE began investing in the nursing home and hospital systems in the early 2000s, allowing for sufficient data to now rigorously study the effect of PE ownership.

Mark-Up Trends in Contemporary Medicare Primary and Revision Total Joint Arthroplasty

BackgroundUnderstanding mark-up ratios (MRs), the ratio between a healthcare institution’s submitted charge and the Medicare payment received, for high-volume orthopaedic procedures is imperative to inform policy about price transparency and reducing surprise billing. This analysis examined the MRs for primary and revision total hip and knee arthroplasty (THA and TKA) services to Medicare beneficiaries between 2013 and 2019 across healthcare settings and geographic regions. MethodsA large dataset was queried for all THA and TKA procedures performed by orthopaedic surgeons between 2013 and 2019, using Healthcare Common Procedure Coding System (HCPCS) codes for the most frequently used services. Yearly MRs, service counts, average submitted charges, average allowed payments, and average Medicare payments were analyzed. Trends in MRs were assessed. We evaluated 9 THA HCPCS codes, averaging 159,297 procedures a year provided by a mean of 5,330 surgeons. We evaluated 6 TKA HCPCS codes, averaging 290,244 procedures a year provided by a mean of 7,308 surgeons. ResultsFor knee arthroplasty procedures, a decrease was noted for HCPCS code 27438 (patellar arthroplasty with prosthesis) over the study period (8.30 to 6.62; P = .016) and HCPCS code 27447 (TKA) had the highest median (interquartile range [IQR]) MR (4.73 [3.64 to 6.30]). For revision knee procedures, the highest median (IQR) MR was for HCPCS code 27488 (removal of knee prosthesis; 6.12 [3.83-8.22]). While no trends were noted for both primary and revision hip arthroplasty, median (IQR) MRs in 2019 for primary hip procedures ranged from 3.83 (hemiarthroplasty) to 5.06 (conversion of previous hip surgery to THA) and HCPCS code 27130 (total hip arthroplasty) had a median (IQR) MR of 4.66 (3.58-6.44). For revision hip procedures, MRs ranged from 3.79 (open treatment of femoral fracture or prosthetic arthroplasty) to 6.10 (revision of THA femoral component). Wisconsin had the highest median MR by state (>9) for primary knee, revision knee, and primary hip procedures. ConclusionThe MRs for primary and revision THA and TKA procedures were strikingly high, as compared to nonorthopaedic procedures. These findings represent high levels of excess charges billed, which may pose serious financial burdens to patients and must be taken into consideration in future policy discussions to avoid price inflation.

Rapid Review of "No Surprise" Medical Billing in the United States: Stakeholder Perceptions and Challenges.

Surprise medical bills received after care delivery in both emergency and non-emergency situations for out-of-network (OON) or other contractual health plan regulations adds additional stress upon the care guarantor, most often the patient. The passing and continued implementation of the federal No Surprises Act (NSA) and related state-level legislation continues to influence the processes of care delivery in the United States. This rapid review evaluated the literature specific to surprise medical billing in the United States since the passing of the No Surprise Act, guided by the preferred reporting items for systematic reviews and meta-analyses (PRISMA) protocol. A total of 33 articles were reviewed by the research team and the results demonstrate industry stakeholder perceptions related to two primary industry themes (constructs) surrounding surprise billing: healthcare stakeholder perspectives and medical claim dispute (arbitration) processes. Further investigation identified sub-constructs for each: the practice of balance-billing patients for OON care and healthcare provider, and facility equitable reimbursement challenges (primary theme 1), and arbitration observations and challenges surrounding (a) the NSA medical dispute process, (b) state-level arbitration processes and perceptions, and (c) use of the Medicare fee schedule as a benchmark for arbitration decisions (primary theme 2). The results indicate the need for formative policy improvement initiatives to address the generation of surprise billing.

Ground Ambulance Billing And Prices Differ By Ownership Structure

The No Surprises Act prohibits most surprise billing but notably does not apply to ground ambulance services. In this study we created a novel data set that identifies the ownership structure of ground ambulance organizations to compare pricing and billing between private- and public-sector ambulances, with a specific focus on organizations owned by private equity or publicly traded companies. Overall, we found that 28percent of commercially insured emergency ground ambulance transports during the period 2014-17 resulted in a potential surprise bill. Our analysis illustrates that being transported by a private-sector ambulance in an emergency comes with substantially higher allowed amounts, patient cost sharing, and potential surprise bills compared with being transported by a public-sector ambulance. Further, allowed amounts and cost sharing tended to be higher for private equity- or publicly traded company-owned ambulances than other private-sector ambulances. These findings highlight substantial patient liability and important differences in pricing and billing patterns between public- and private-sector ground ambulance organizations.

Definition, Practice, Regulations, and Effects of Balance Billing: A Scoping Review.

Additional billing is commonly and legally practiced in some countries for patients covered by health insurance. However, knowledge and understanding of the additional billings are limited. This study reviews evidence on additional billing practices including definition, scope of practice, regulations and their effects on insured patients. A systematic search of the full-text papers that provided the details of balance billing for health services, written in English, and published between 2000 and 2021 was carried out in Scopus, MEDLINE, EMBASE and Web of Science. Articles were screened independently by at least 2 reviewers for eligibility. Thematic analysis was applied. In total, 94 studies were selected for the final analysis. Most of the included articles (83%) reported findings from the United States (US). Numerous terms of additional billings were used across countries such as balance billing, surprise billing, extra billing, supplements and out-of-pocket (OOP) spending. The range of services incurred these additional bills also varied across countries, insurance plans, and healthcare facilities; the frequently reported were emergency services, surgeries, and specialist consultation. There were a few positive though more studies reported negative effects of the substantial additional bills which undermined universal health coverage (UHC) goals by causing financial hardship and reducing access to care. A range of government measures had been applied to mitigate these adverse effects, but some difficulties still exist. Additional billings varied in terms of terminology, definitions, practices, profiles, regulations, and outcomes. There were a set of policy tools aimed to control substantial billing to insured patients despite some limitations and challenges. Governments should apply multiple policy measures to improve financial risk protection to the insured population.

The Impact of Surprise Billing Laws on Emergency Services

The Impact of Surprise Billing Laws on Emergency Services

Surprise Billing Legislation: Context and Significance for Plastic and Reconstructive Surgeons.

1Division of Plastic and Reconstructive Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin Financial Disclosure Statement: The authors have no financial disclosures. Corresponding Author: Venkat K. Rao, MD MBA Division of Plastic and Reconstructive Surgery 600 Highland Ave. CSC G5/355 Madison, WI 53792 USA Email: [email protected]

Variation in Public Support for Government Action on Unexpected Medical Bills.

Nearly half of the adults in the United States have received an unexpected medical bill in recent years. While government, provider, and insurance policies related to unexpected medical expenses receive attention in the media, this study focuses on variation in public support. The study employs two multifactor survey vignette experiments to detect how different features of common health care scenarios that result in costly medical expenses influence the public's sympathy for the patient, perceived fairness of the medical costs, and demand for government action. The results point to out-of-pocket cost, severity of the treatment, and the patient's insurance situation as important for public opinion. The public is significantly more supportive of government action when the costs are high and out of the patient's control; in contrast, respondents are generally less sympathetic toward patients described as uninsured or who seek out more costly providers. The findings underscore the sensitivity of health care attitudes to framing effects, which may occur when media choose how to cover health care costs. The results also point to a potential mismatch in legislation that narrowly addresses "surprise billing," with public support for government addressing disproportionate costs across a broader range of scenarios.