About 1 in 8 commercially insured patients received potential surprise bill for colonoscopy
Of more than 1 million elective colonoscopies in commercially insured U.S. patients, about 12% involved out-of-network claims at a median cost of $418 per potential surprise bill, a study found.
About one in eight commercially insured patients who had an elective colonoscopy incurred an out-of-network claim when the endoscopist and facility were both in network, a study found.
Researchers estimated the prevalence, amount, and source of out-of-network claims for commercially insured patients having an elective colonoscopy. They queried a claims database from a large national insurer for commercially insured patients ages 18 to 64 years who had a colonoscopy between 2012 and 2017. Cases coded as elective with a stay of one day or shorter were included, and the analysis was restricted to cases in which both the facility and the endoscopist were in network. The primary outcome measure was the prevalence of out-of-network claims when the endoscopist and facility were in network. The secondary outcome was the amount of the potential surprise bill in these scenarios, calculated as the total out-of-network charges less the typical in-network price. Results were published online on Oct. 13 as a brief research report by Annals of Internal Medicine.
Overall, there were 1,118,769 elective colonoscopies with in-network endoscopists and facilities; of these, 12.1% (95% CI, 11.2% to 13.1%; n=135,626) involved out-of-network claims. The median potential surprise bill was $418 (interquartile range, $152 to $981). Out-of-network anesthesiologists were involved in 64% of cases (median potential surprise bill, $488; interquartile range, $145 to $1,186), and out-of-network pathologists were involved in 40% (median potential surprise bill, $248; interquartile range, $153 to $554). The likelihood of an out-of-network claim was significantly higher when an intervention was done during colonoscopy than in cases without intervention (13.9% vs. 8.2%; difference, 5.7% [95% CI for difference, 4.9% to 6.5%]). When interventions were performed, 56% of potential surprise bills involved anesthesiologists and 51% involved pathologists. In cases with visual inspection only, 95% of potential surprise bills involved anesthesiologists.
Limitations of the study include a lack of detailed clinical information to supplement the billing data and the inability to determine the true cost of potential surprise bills, the authors noted. “To mitigate future effects on screening colonoscopy use, endoscopists and endoscopy facilities should ensure that they are partnering with anesthesia and pathology providers who participate in insurance networks,” they concluded. “In the short term, endoscopists should also consider using established cost-saving strategies, such as conscious sedation and the ‘resect and discard’ approach, to biopsy specimens.”