美国密歇根大学Justin B. Dimick研究小组近日取得一项新成果。经过不懈努力，他们发现商业保险患者由网络内医生和设施行择期手术较容易收到网外账单。相关论文2020年2月11日发表于国际顶尖学术期刊《美国医学会杂志》上。

接受保险网络内医生治疗的商业保险患者也可能收到意外的网外账单（意外账单）。在择期手术中，若患者选择保险网络内的医生和医院，就有可能收到其他临床医生的网外账单。

研究组对一家美国大型商业保险公司的索赔数据进行了回顾性分析，2012年1月1日至2017年9月30日，共有347356名患者施行了常见的择期手术，平均年龄为48岁，66%为女性。

有20.5%的患者收到了网外账单，平均每笔为2011美元。37%的网外账单与外科助理有关，平均每笔3633美元。37%的网外账单与麻醉师有关，平均每笔为1219美元。

健康保险交换计划成员收到网外账单的概率为27%，显著高于非交换计划成员（20%）。有手术并发症的患者收到网外账单的风险为28%，显著高于没有并发症的患者（20%）。在83021个由网络内外科医生在门诊中心进行的手术中，6.7%会收到网外设施账单，17.2%会收到网外专业账单。

总之，商业保险患者在保险网络内的设施由网络内外科医生行择期手术时，较大概率会收到网外账单。

附：英文原文

Title: Out-of-Network Bills for Privately Insured Patients Undergoing Elective Surgery With In-Network Primary Surgeons and Facilities

Author: Karan R. Chhabra, Kyle H. Sheetz, Ushapoorna Nuliyalu, Mihir S. Dekhne, Andrew M. Ryan, Justin B. Dimick

Issue&Volume: 2020/02/11

Abstract:

Importance  Privately insured patients who receive care from in-network physicians may receive unexpected out-of-network bills (“surprise bills”) from out-of-network clinicians they did not choose. In elective surgery, this can occur if patients choose in-network surgeons and hospitals but receive out-of-network bills from other involved clinicians.

Objective  To evaluate out-of-network billing across common elective operations performed with in-network primary surgeons and facilities.

Design, Setting, and Participants  Retrospective analysis of claims data from a large US commercial insurer, representing 347?356 patients who had undergone 1 of 7 common elective operations (arthroscopic meniscal repair [116?749]; laparoscopic cholecystectomy [82?372]; hysterectomy [67?452]; total knee replacement [42?313]; breast lumpectomy [18?018]; colectomy [14?074]; coronary artery bypass graft surgery [6378]) by an in-network primary surgeon at an in-network facility between January 1, 2012, and September 30, 2017. Follow-up ended November 8, 2017.

Exposure  Patient, clinician, and insurance factors potentially related to out-of-network bills.

Main Outcomes and Measures  The primary outcome was the proportion of episodes with out-of-network bills. The secondary outcome was the estimated potential balance bill associated with out-of-network bills from each surgical procedure, calculated as total out-of-network charges less the typical in-network price for the same service.

Results  Among 347?356 patients (mean age, 48 [SD, 11] years; 66% women) who underwent surgery with in-network primary surgeons and facilities, 20.5% of episodes (95% CI, 19.4%-21.7%) had an out-of-network bill. In these episodes, the mean potential balance bill per episode was $2011 (95% CI, $1866-$2157) when present. Out-of-network bills were associated with surgical assistants in 37% of these episodes; when present, the mean potential balance bill was $3633 (95% CI, $3384-$3883). Out-of-network bills were associated with anesthesiologists in 37% of episodes; when present, the mean potential balance bill was $1219 (95% CI, $1049-$1388). Membership in health insurance exchange plans, compared with nonexchange plans, was associated with a significantly higher risk of out-of-network bills (27% vs 20%, respectively; risk difference, 6% [95% CI, 3.9%-8.9%]; P < .001). Surgical complications were associated with a significantly higher risk of out-of-network bills, compared with episodes with no complications (28% vs 20%, respectively; risk difference, 7% [95% CI, 5.8%-8.8%]; P < .001). Among 83?021 procedures performed at ambulatory surgery centers with in-network primary surgeons, 6.7% (95% CI, 5.8%-7.7%) included an out-of-network facility bill and 17.2% (95% CI, 15.7%-18.8%) included an out-of-network professional bill.

Conclusions and Relevance  In this retrospective analysis of commercially insured patients who had undergone elective surgery at in-network facilities with in-network primary surgeons, a substantial proportion of operations were associated with out-of-network bills.

DOI: 10.1001/jama.2019.21463

Source: https://jamanetwork.com/journals/jama/article-abstract/2760735