Colonoscopy patients often get surprise out-of-network bills

Last Updated: 2020-10-12

By Linda Carroll

(Reuters Health) - Surprise out-of-network bills greet nearly one in eight patients who get a colonoscopy in the U.S., a new study finds.

An analysis of a large national insurer's claims data on colonoscopies performed during a six year period revealed that 12% of patients received bills that included out-of-network charges, according to the report published in the Annals of Internal Medicine.

The most common sources of these unexpected bills were from out-of-network anesthesiologists and pathologists, the researchers found.

"We all have to work together to make sure the patient is not harmed," said lead author Dr. James Scheiman, the David Stone Professor and chief of the division of gastroenterology and hepatology at the University of Virginia. "We should have transparent, fair pricing and there should be tools to help patients figure this out."

Dr. Scheiman fears that these sorts of surprise bills could scare people off from getting colonoscopies. "This is the most effective and cost effective screening tool we have for patients," he said. "These out of pocket costs will hurt people financially and make them less willing to undergo this valuable procedure."

Dr. Scheiman and his colleagues reviewed roughly 1.1 million colonoscopies involving patients aged 18 to 64 who had a colonoscopy between 2012 and 2017. Cases coded as elective with a stay of one day or less were included in their analysis.

They focused on cases in which both the facility and the endoscopist were in-network--situations in which patients would not expect any extra charges. The researchers stratified the cases into those involving visual inspection alone and those that included an intervention.

Overall, 12.1% of the cases involved out-of-network charges. The median potential "surprise" bill was $418. Out-of-network anesthesiologists were involved in 64% of these cases with a median potential surprise bill of $488 (interquartile range, $145 to $1,186). Out-of-network pathologists were involved in 40% of cases, with a potential surprise bill of $248 (interquartile range of $153 to $554).

The likelihood of an out-of-network claim was significantly higher in cases with vs without an intervention: 13.9% versus 8.2%. When interventions were performed, 56% of potential surprise bills involved anesthesiologists and 51% involved pathologists.

In cases with visual inspection alone, 95% of potential surprise bills involved anesthesiologists. The researchers found those cases especially concerning. "This outcome is disconcerting because Section 2713 of the Patient Protection and Affordable Care Act eliminates consumer cost sharing for screening colonoscopy and because a recent Federal Reserve study reported that 40% of Americans do not have $400 to cover unexpected expenses," the researchers write.

One possible solution is to offer a bundled price for colonoscopies, Dr. Scheiman said.

The situation described by the researchers "represents a failure of the way we pay for healthcare in the U.S.," said Dr. Albert Wu, an internist and a professor of health policy and management at the Johns Hopkins School of Public Health. "No one is in control here and able to look out for the little guy, the consumer who is already apprehensive about getting the procedure," Dr. Wu said.

"The ACA acknowledged the clear evidence that colon cancer screening saves live by protecting consumers from out of pocket costs for screening colonoscopy," Dr. Wu said. "Sadly, this has not proved enough to overcome the inexorable ability of American healthcare to wring as many dollars out of people as possible. In this case it's accomplished by 'out-of-network billing."

Doctors involved in colonoscopies need to play a bigger role in protecting patients, Dr. Wu said.

"In the current absence of a policy solution, the physicians who derive substantial income from doing the procedure should share part of the responsibility for protecting their patients," he added. "They can do this by ensuring that everyone on their team is in an insurance network. They should make sure that their care does not burden their patients from unexpected bills that they can't afford."

SOURCE: https://bit.ly/33Rwgxu Annals of Internal Medicine, online October 12, 2020.