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Out-of-Network Claims Fairly Common for Elective Colonoscopy

Out-of-network claims involved anesthesiologist, pathologist in 64, 40 percent of cases, respectively

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TUESDAY, Oct. 13, 2020 (HealthDay News) -- Out-of-network claims were incurred by 12.1 percent of commercially insured patients who underwent elective colonoscopy between 2012 and 2017, according to a study published online Oct. 12 in the Annals of Internal Medicine.

James M. Scheiman, M.D., from the University of Virginia in Charlottesville, and colleagues estimated the prevalence, amount, and source of out-of-network claims for commercially insured patients undergoing elective colonoscopy. Data were included for 1,118,769 elective colonoscopies with in-network endoscopists and facilities.

The researchers found that 12.1 percent of the endoscopies involved out-of-network claims, with a median potential surprise bill of $418. Sixty-four percent of the cases involved out-of-network anesthesiologists (median potential surprise bill, $488), while 40 percent involved out-of-network pathologists (median potential surprise bill, $248). Compared with cases without intervention, when an intervention was done during colonoscopy, the likelihood of an out-of-network claim was significantly higher (13.9 versus 8.2 percent). When interventions were performed, 56 and 51 percent of potential surprise bills involved anesthesiologists and pathologists, respectively. Ninety-five percent of surprise bills involved anesthesiologists in cases with visual inspection only.

"It is essential to develop tools that provide patients an estimate of their financial responsibility before their colonoscopy is done and better protect them from potential financial harm," the authors write.

Two authors disclosed ties to the health insurance industry and one disclosed ties to the pharmaceutical industry.

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