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Editor's Note
February 11, 2020

Surprise Billing in Surgery—Time for Action

Author Affiliations
  • 1Washington University School of Medicine
  • 2Associate Editor, JAMA
  • 3Deputy Editor, JAMA
JAMA. 2020;323(6):547. doi:10.1001/jama.2019.21461

“Surprise” billing occurs when patients with health insurance receive care from a clinician or facility included in their insurer’s network (“in-network”) but unexpectedly receive “surprise” bills from other clinicians involved in their care who are not in the patient’s insurer’s network (“out-of-network”) and therefore not covered by their insurance. In this issue of the JAMA, Chhabra and colleagues1 present a thorough analysis of out-of-network billing for elective operations and find the practice to be both common and potentially financially devastating. Based on their analysis of 347 356 patients who had undergone 1 of 7 common elective operations with in-network surgeons at in-network facilities, the authors report that 20.5% of these surgical episodes also had an associated out-of-network bill, with a mean potential financial liability of more than $2000. The most common sources of the out-of-network bills were surgical assistants and anesthesiologists.

The evidence provided by Chhabra et al1 adds to an increasing literature on the prevalence and size of these “surprise” bills for privately insured patients.2,3 Such billing practices are particularly pernicious because patients usually have no knowledge that they will occur, and no way to avoid them.

Clinicians and policy makers alike should act to end this practice. First, surgeons have an ethical responsibility to speak out against surprise billing. Patients generally select surgeons because they have faith that the surgeon they choose will provide them with the best possible care. This crucial trust between patient and physician will be eroded if patients discover after an operation that they must pay large sums of money to other clinicians the surgeon has involved in their care. When feasible, surgeons should ensure that all the personnel involved in the care team that they are leading accept the same insurance plans and should consider refusing to work in facilities that allow surprise billing.

Second, Congress needs to act to eliminate surprise billing. While some states have enacted surprise billing legislation, Chhabra et al1 found no relationship between states’ surprise billing policies and patients’ financial liability resulting from these out-of-network bills, suggesting broader change is necessary. In 2019, the US Senate proposed the Lower Health Care Costs Act4 and the House proposed the No Surprises Act,5 which would require patients to pay only the in-network cost-sharing amount (ie, deductibles or co-insurance) for out-of-network care provided at in-network facilities without the patient’s informed consent. There has been pushback from physician groups, particularly those backed by private equity firms, who argue that such legislation will have potentially negative consequences for clinicians by reducing their leverage to negotiate fair reimbursement.6 While it is important that legislation take these issues into account, it is crucial that patients’ interests remain paramount.

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Article Information

Conflict of Interest Disclosures: Dr Joynt Maddox reported receiving grants from the National Institutes of Health (NIH)/National Heart, Lung, and Blood Institute, the NIH/National Institute in Aging, and the Commonwealth Fund and receiving compensation for previous contract work from the US Department of Health and Human Services. No other disclosures were reported.

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 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  [published online August 12, 2019].  JAMA Intern Med. doi:10.1001/jamainternmed.2019.3451PubMedGoogle Scholar
Cooper  Z, Nguyen  H, Shekita  N, Morton  FS.  Out-of-network billing and negotiated payments for hospital-based physicians.  Health Aff (Millwood). 2020;39(1):24-32. doi:10.1377/hlthaff.2019.00507PubMedGoogle ScholarCrossref
Lower Health Care Costs Act, S 1895, 116th Cong (2019-2020).
No Surprises Act, HR 3630, 116th Cong (2019-2020).
Sanger-Katz  M, Creswell  J, Abelson  R. Mystery solved: private-equity-backed firms are behind ad blitz on “surprise billing.” New York Times.https://www.nytimes.com/2019/09/13/upshot/surprise-billing-laws-ad-spending-doctor-patient-unity.html. September 14, 2019.