Out-of-Pocket Costs and Surprise Billing in Otolaryngology: A National Database Analysis.

Abstract

To evaluate out-of-pocket (OOP) costs and surprise billing (unexpected charges from out-of-network providers) in otolaryngology. Retrospective cohort study. National commercial claims database. Merative MarketScan database was queried for commercially insured patients aged 18 to 64 who underwent any of six otolaryngology procedures (thyroidectomy, parotidectomy, hypoglossal nerve stimulator implantation, drug-induced sleep endoscopy, septoplasty, or tonsillectomy) from 2014 to 2022. OOP costs were defined as the sum of deductibles, copays, and coinsurance for each 30-day surgical episode. A potential surprise bill was defined as an out-of-network claim within an episode where both the primary surgeon and facility were in-network. Relationships between OOP costs, potential surprise bills, and patient- and system-level exposures were analyzed. Of 58,772 procedures meeting inclusion criteria, 52,131 (89%) procedures were outpatient and 6641 (11%) were inpatient. Median (interquartile range [IQR]) total OOP costs were $1207 ($183-$2594), and coinsurance accounted for 66% of OOP costs. OOP costs were higher for patients with insurance plans that were fee-for-service-based (2.9 times; P < .001) or high-deductible (4.7 times; P < .001) versus managed care plans. A potential surprise bill accompanied 4.8% of surgical encounters, which was associated with significantly higher OOP costs (median $1739 vs $1269; P < .001). The odds of having a potential surprise bill were lower in 2022 versus 2014 to 2021 (odds ratio [OR] 0.29, 95% CI 0.21-0.40; P < .001). Common elective otolaryngology procedures were associated with high OOP expenditures, potentially exceeding the reserve funds of many patients. Potential surprise bills decreased after the passage of the No Surprises Act but were not eliminated.