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Editor's Comment
February 11, 2020

Surprise Billing Prevalent Even for Elective Surgeries—Congress, Take Note

Author Affiliations
  • 1Deputy Editor, JAMA Health Forum
  • 2Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
JAMA Health Forum. 2020;1(2):e200125. doi:10.1001/jamahealthforum.2020.0125

The study published by Chhabra et al1 today could not come at a more critical time. The US House and Senate committees are working on legislation to address the issue of surprise bills. As Chhabra et al explain, these “bills occur when patients obtain care for physicians and hospitals that participate in their insurance network (‘in network’) but receive separate and often unexpected bills from a clinician who does not participate in their insurance network.”1(p2) Their study adds to work published last year by Sun et al2 in JAMA Internal Medicine that found that in 2016 more than 40% of emergency room visits and inpatient admissions to an in-network facility had an associated surprise bill for out-of-network services. The new study1 in JAMA examines elective surgeries, a condition for which people have the ability to choose an in-network provider in advance. Yet still, 20.5% of surgeries with in-network primary surgeons at in-network facilities yielded an out-of-network bill, and the mean amount of those bills was thousands of dollars. The bills were most often for an anesthesiologist or an assistant at surgery—the types of services that a typical patient would not think to ask about in advance.

These data add to the widespread sense that surprise billing is prevalent and unfair and illustrate that it is not isolated to a limited set of private equity–backed medical groups. What they unfortunately cannot shed light on is which of the policy solutions on the table will best solve the problem. Hopefully, a compromise will be reached between those in Congress who favor setting a benchmark rate for compensating out-of-network providers in these situations and those who favor arbitration between insurers and out-of-network providers. What is not the subject of debate among lawmakers is that patients should not be left paying these bills in full—and yet that is exactly what will happen if Congress is not able to agree on a path forward.

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Article Information

Open Access: This is an open access article distributed under the terms of the CC-BY License.

Chhabra  KR, Sheetz  KH, Nuliyalu  U, Dekhne  MS, Ryan  AM, Dimick  JB.  Out-of-network bills for privately insured patients undergoing elective surgery with in-network primary surgeons and facilities  [published online February 11, 2020].  JAMA. doi:10.1001/jama.2019.21463Google Scholar
Sun  EC, Mello  MM, Moshfegh  J, Baker  LC.  Assessment of out-of-network billing for privately insured patients receiving care in in-network hospitals.   JAMA Intern Med. 2019;179(11):1543-1550. doi:10.1001/jamainternmed.2019.3451PubMedGoogle ScholarCrossref
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