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Nearly one in eight commercially insured patients undergoing elective colonoscopy with in-network providers incurred out-of-network costs, researchers found -- potentially leading to illegal "surprise bills."

In an analysis of a national claims database, and among 118,769 elective colonoscopies with in-network endoscopists and facilities, 12.1% (95% CI 11.2-13) involved out-of-network claims. The median potential surprise bill was $418, according to James M. Scheiman, MD, of the University of Virginia in Charlottesville, and colleagues ("potential" because the investigators didn't have access to actual bills, but instead made estimates based on records of in- versus out-of-network coverage).

Of particular concern was that one in 12 procedures without an associated intervention still had an out-of-network claim, they explained in a brief research report in the.

"This outcome is disconcerting because Section 2713 of the Patient Protection and Affordable Care Act [ACA] eliminates consumer cost sharing for screening colonoscopy and because a recent reported that 40% of Americans do not have $400 to cover unexpected expenses," the investigators wrote.

Moreover, out-of-pocket costs are well-established deterrents to evidence-based care and fuel patient dissatisfaction, they noted. They urged endoscopists and their facilities to partner with anesthesia and pathology providers who participate in their insurance networks.

"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," the authors wrote. "In the longer term, we must enhance ongoing reform efforts to remove consumer cost sharing for all clinically indicated care associated with colonoscopy."

Although reports of surprise billing are increasingly common, the study was designed to provide precise quantification of its extent, according to Scheiman's group. They queried the claims database of a large national carrier for commercially insured patients, ages 18 to 64 years, undergoing elective colonoscopy from 2012 to 2017.

The primary outcome was the prevalence of out-of-network claims when the endoscopist and facility were in-network. As a secondary outcome, the researchers calculated the potential surprise bill in these scenarios, calculated as the total out-of-network charges less than the typical in-network price. They explained that they used this method in previous research because claims data do not include amounts billed to patients.

By practice type, out-of-network anesthesiologists topped the list for extra billings at 64% of cases, with a median potential surprise bill of $488. Next came pathologists, who accounted for 40% of surprise billings with a potential price tag per case of $248.

The likelihood of an out-of-network claim was significantly higher when an intervention -- biopsy rather than visual inspection, for example -- was done during colonoscopy than in cases without intraoperative intervention (13.9% vs 8.2%, 5.7% difference, 95% CI 4.9-6.5).

When such 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.

Study limitations included the fact that the "estimates are derived from insurance claims, and we did not have detailed clinical information to supplement the billing data," the authors stated. Also, they could not determine the precise magnitude of a potential balance bill and relied on previously for estimating potential financial liability.

Health policy analyst Karen Joynt Maddox, MD, MPH, of Washington University School of Medicine in St. Louis, called the study the latest in a growing number that show how common this practice is in U.S. medicine.

"Surprise billing is really problematic because patients often have no way to protect themselves from the surprise bill. They can go to a gastroenterologist in-network, at a surgical facility in-network, and still get a surprise bill from someone who they may not even have known was involved in their procedure," said Joint Maddox, who was not involved in this study.

This is particularly concerning for the preventive procedure of colonoscopy, which should be covered without cost-sharing, she added.

Joynt Maddox called for legislation to correct this practice, but she also noted that some fixes proposed by policymakers have not been supported by healthcare professionals.

"But ultimately the people losing are the patients, so we need to find a path forward to end surprise billing," she said. "In my opinion, it should not be allowed to bill a patient out-of-network rates for something that could reasonably have expected to be in-network, like an out-of-network surgical or procedural assistant when the primary surgeon and facility are in-network."

Study co-author Karan R. Chhabra, MD, of Harvard Medical School in Boston, agreed, stating that "I don't think the onus should be on patients to prevent surprise bills, which represent a failure of our healthcare and policymaking systems. Screening colonoscopies are supposed to be entirely free of cost-sharing according to the ACA, so any out-of-pocket payment obligation in this setting is unacceptable."

Chhabra advised patients to inquire about out-of-network providers before they undergo endoscopy or surgery, adding that "physicians should also make themselves aware of the billing practices at centers where they practice. Ideally, they should do their colonoscopies at facilities where all providers participate in the same major insurance plans."

Per the study, cost-incurring anesthesiology and pathology review are not necessary in all cases. "Endoscopists can perform their own sedation, and in certain settings, lesions can be discarded without pathological examination," Chhabra said.

Chhabra and colleagues published a similar analysis in February 2020, showing that one in five patients who underwent a range of elective surgeries within their insurance network faced even higher surprise costs from out-of-network anesthesiologists, surgical assistants, pathologists, medical consultants, and radiologists.

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