Studies Examine Surprise Billing for Ambulance Rides, ASC Visits

A pair of studies released ahead of the next edition of Health Affairs examined the prevalence of surprise billing and out-of-network charges for ambulance rides and ambulatory surgery center (ASC) visits.

Surprise billing is one of the healthcare industry’s biggest pain points. These bills typically occur when patients receive care from a provider outside of their plan’s network even though they are rendering care at an in-network facility.

These bills are unexpected and oftentimes very high since the health plan does not provide discounts for out-of-network services. This has led policymakers to prioritize the banning of surprise billing in future legislation prior to the COVID-19 pandemic.

But new studies show that surprise billing is more common in certain healthcare settings.

The study conducted by researchers at the University of Michigan found that most patients (71 percent) in a large national insurance plan received out-of-network bills for ground and air ambulance transportation between 2013 and 2017, and those bills were usually sizable.

The median potential surprise bills were $450 for ground transportation and $21,698 for air transportation. And though out-of-network air ambulance bills were larger, out-of-network ground ambulance bills were more common, resulting in a total of $129 million in potential surprise bills per year, the study of data from the Clinformatics DataMart Database showed.

Researchers also found that 79 percent of ground transportation providers used during medical emergencies were out of network.

While the finding underscores the difficulty of choosing an in-network provider during an emergency, researchers also found that 52 percent of encounters were out of network in non-emergency situations.

Meanwhile, individuals were less likely to receive potential surprise bills from visiting an ASC, a separate study found.

Researchers at the Leonard D. Schaeffer Center for Health Policy and Economics at the University of Southern California examined 4.2 million ASC-based episodes of care from around the US between 2014 and 2017. They used a database of claims from several of the country’s largest commercial insurers.

Of the ASC-based episodes, 10 percent involved patients being treated at an in-network ASC, but they involuntarily received out-of-network provider care.

Potential surprise bills from ASCs occurred just as often as from hospitals, and most of the bills from ASCs involved out-of-network ancillary providers whom patients did not choose or could not avoid, researchers stressed.

However, in nearly a quarter of the ASC-based episodes that had the potential to result in a surprise bill because of out-of-network care, health plans paid the full bill charged, the study showed. The potential surprise bills averaged $1,483 in 2017.

“While these patients are protected from receiving an unexpected bill, it means that enrollees in these plans pay higher premiums,” explained Erin Trish, co-author of the study and the associate director of the USC Schaeffer Center and assistant professor at the USC School of Pharmacy.

The findings highlight the need for federal action, researchers argued.

“ASCs are an important and often overlooked part of the surprise billing discussion,” said Erin Duffy, the Schaeffer Center post-doctoral fellow. “These surgery centers are increasingly used and patients assume if the center is in-network their care will be. What our research shows is that is often not the case.”

Major surprising billing proposals including the Lower Health Care Costs Act of 2019 have centered on hospital and air ambulance bills. Policymakers have yet to agree on how to prohibit surprise billing but acting now could help patients handle the COVID-19 crisis.

Independent laboratories accounted for 10 percent of potential surprise bills from ASC-based episodes of care, Duffy, Trish, and others found. Pathologists represented three percent.

“The study’s findings are especially resonant during the COVID-19 pandemic, as the findings suggest the laboratories charged with analyzing tests for the virus have the potential to surprise bill,” they stated in a press release.

The Coronavirus Aid, Relief and Economic Security (CARES) Act signed into law last month mandates payers to cover the list costs of COVID-19 test performed by out-of-network providers and prohibits providers from balance billing COVID-19 patients if they want to receive emergency funding.

However, the CARES Act does not place limits on how high lists prices for COVID-19 tests can be, which could result in payers increasing premiums after paying high balances, researchers stated.

But the law could be a major step for the prohibition of surprise billing.

In guidance posted on HHS’ website, the federal department states that it “broadly views every patient as a possible case of COVID-19.” Interpretations of the law explain that this could mean providers cannot balance bill any patients during the pandemic.