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Wang KY, Suresh KV, Harris A, et al. Out-of-Network Billing in Privately Insured Patients Undergoing Elective Orthopaedic Surgery. J Am Acad Orthop Surg. 2021;29(24):1072-1078doi: 10.5435/JAAOS-D-21-00081.
Wang, K. Y., Suresh, K. V., Harris, A., Marrache, M., Puvanesarajah, V., Levy, J., & Jain, A. (2021). Out-of-Network Billing in Privately Insured Patients Undergoing Elective Orthopaedic Surgery. The Journal of the American Academy of Orthopaedic Surgeons, 29(24), 1072-1078. https://doi.org/10.5435/JAAOS-D-21-00081
Wang, Kevin Y, et al. "Out-of-Network Billing in Privately Insured Patients Undergoing Elective Orthopaedic Surgery." The Journal of the American Academy of Orthopaedic Surgeons vol. 29,24 (2021): 1072-1078. doi: https://doi.org/10.5435/JAAOS-D-21-00081
Wang KY, Suresh KV, Harris A, Marrache M, Puvanesarajah V, Levy J, Jain A. Out-of-Network Billing in Privately Insured Patients Undergoing Elective Orthopaedic Surgery. J Am Acad Orthop Surg. 2021 Dec 15;29(24):1072-1078. doi: 10.5435/JAAOS-D-21-00081. PMID: 34297702.
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J Am Acad Orthop Surg. 2021 Dec 15;29(24):1072-1078. doi: 10.5435/JAAOS-D-21-00081.

Out-of-Network Billing in Privately Insured Patients Undergoing Elective Orthopaedic Surgery.

The Journal of the American Academy of Orthopaedic Surgeons

Kevin Y Wang, Krishna V Suresh, Andrew Harris, Majd Marrache, Varun Puvanesarajah, Joseph Levy, Amit Jain

Affiliations

  1. From the Department of Orthopaedic Surgery (Wang, Suresh, Harris, Marrache, Puvanesarajah, and Jain), Johns Hopkins University School of Medicine, and the Department of Health Policy and Management (Levy), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.

PMID: 34297702 DOI: 10.5435/JAAOS-D-21-00081

Abstract

BACKGROUND: Out-of-network charges during hospital care can result in unexpected or surprise bills for the patient. The aim of this study was to ascertain the frequency of out-of-network (OON) billing by the primary orthopaedic surgeon for commonly performed elective, inpatient procedures: total hip arthroplasty (THA), total knee arthroplasty (TKA), anterior cervical diskectomy and fusion (ACDF), and posterior lumbar fusion (PLF).

METHODS: Patients undergoing TKA, THA, one-level ACDF, and one-level PLF from 2010 to 2018 were queried using a commercially insured claims database with Current Procedural Terminology codes. The in-network (IN) versus OON status of the primary surgeon's submitted charges and the payor's reimbursement was recorded for each case. All costs were adjusted for inflation and reported in terms of 2018 real dollars. Bivariate analyses were performed.

RESULTS: Among the 549,868 elective orthopaedic cases, 6.7% were billed as OON by the primary orthopaedic surgeon: 6.1% TKA cases, 6.5% THA, 9.9% ACDF, and 8.5% PLF. From 2010 to 2018, a declining trend was seen in proportion of cases billed as OON by orthopaedic surgeons (P < 0.001 for each case). Mean reimbursement for claims paid as OON was 2.6 times higher than claims paid at the IN rate (range: 1.5 to 3.1 times higher; P < 0.001). The mean OON payments were higher by $1,284 for TKA, $2,516 for THA, $10,097 for ACDF, and $15,104 for PLF compared with mean IN payments (P < 0.001 for each). Compared with health maintenance organization-type plans, preferred provider organization-type plans reimbursed a greater percentage of the submitted claims at the OON rate (14.3% versus 44.5%, P < 0.001).

CONCLUSION: OON billing by the orthopaedic surgeon for TKA, THA, ACDF, and PLF is an uncommon and declining phenomenon.

LEVEL OF EVIDENCE: IV.

Copyright © 2021 by the American Academy of Orthopaedic Surgeons.

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