Surprise Out-of-Network Bills in Ambulance Encounters of Hand and Upper Extremity Patients
Jung Ho Gong, AB1, Chao Long, MD, MPH2,3, Gongliang Zhang, PhD, MS3 and Aviram M Giladi, MD, MS4, (1)Warren Alpert Medical School of Brown University, Providence, RI, (2)Johns Hopkins Medicine, Baltimore, CA, (3)The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD, (4)The Curtis National Hand Center, Baltimore, MD
Introduction: Surprise billing occurs when patients are charged out-of-network fees at an in-network facility. Congress passed the No Surprises Act in December 2020 to protect patients from surprise billing, but it does not cover ground ambulance services. While the ambulance can be used for initial presentation to the hospital or interhospital transfer, patients transferred between hospitals have less control over the network status of the ambulance and subsequent services. In this study, we aimed to assess the occurrence of surprise billing in the two types of ambulance services for hand and upper extremity trauma patients.
Materials and Methods: We used 2010-2018 IBM MarketScan database to identify encounters with both ambulance services and hand procedures based on 44 ambulance and 49 hand Healthcare Common Procedure Coding System codes. We defined surprise billing encounters as those with an in-network service and out-of-network payment or those that included both an in-network facility claim and an out-of-network provider claim or payment. We defined interhospital ambulance transfers as those to facilities providing equal or higher levels of care. We created multivariable regression models by adjusting for patient age, sex, region, employment status, and insurance type to estimate the odds of surprise billing in ambulance encounters with interhospital transfers compared to those for initial hospital presentations. We also assessed trends in surprise billing over time.
Results: Of 120,423 ambulance encounters associated with hand and upper extremity procedures, 39,674 (32.9%) involved interhospital transfers. The overall incidence of surprise billing increased from 73.9% in 2010 to 84.9% in 2018 (r2 0.78). The incidence rates of surprise billing for encounters with interhospital transfers and those with initial presentations to the hospital were 80.4% (N=31,903) and 80.5% (N=64,986; P=0.79), respectively. After adjusting for covariates, there was minimal difference in odds of surprise billing in the interhospital transfer group compared to the initial presentation group (AOR 1.00; 95% CI 0.99-1.00; P<0.001).
Conclusions: Incidences of surprise billing were high in privately insured hand and upper extremity patients who required ground ambulance transfer, and surprise billing has become more prevalent in recent years. The odds of surprise billing were not impacted by ambulance transfer type. Considering that recent Congressional efforts to protect patients from surprise billing do not include all ambulance services, it is imperative to continue monitoring how surprise billing practices in the United States impact trauma patients.
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