A patient decides to undergo elective surgery. She acts responsibly by researching her coverage. After a few time-consuming calls, the patient is assured the hospital of choice is in-network.

Patient access staff play their parts, too. When the patient calls to schedule the surgery, they verify the insurance as in-network and carefully review the out-of-pocket costs with the patient.

Everything seems in order — yet weeks later, an unpleasant surprise bill arrives at the patient’s house. It is not from the hospital, but from an out-of-network provider who was involved in the patient’s care at some point during her hospital stay. The patient does not even recognize the physician’s name. Not surprisingly, her first call is to the hospital to complain.

In one recent case involving this frustrating scenario, a patient underwent cardiothoracic surgery at The MetroHealth System in Cleveland. No one realized the surgeon was not in-network and was under contract with another facility. The patient received a bill on the other facility’s letterhead.

The patient’s daughter handed the mystery bill to Kenneth W. Kirby, CHAM, CHTS – TR, admitting manager. At first, it seemed something had been entered into the system incorrectly. Shortly afterward, Kirby spoke with a co-worker whose husband had received an out-of-network bill from the same surgeon. The true reason for the surprise bill became clear; it was much more complicated than just a system error. “I realized that the surgeon was not an employee of our hospital,” Kirby says.

There are new data on just how often these surprise out-of-network bills are sent — about 14% of the time, on average.1 “The topic of surprise billing has become increasingly important in today’s healthcare climate,” says study co-author Jean Fuglesten Biniek, PhD.

Surprise medical bills have been debated in state- and federal-level policy discussions, media reports on individual patient experiences, and recent academic literature. “The issue of receiving out-of-network care at an in-network facility has become particularly relevant,” Fuglesten Biniek notes.

However, data on just how often this was happening were lacking. “We wanted to provide some numbers as to how prevalent this phenomenon is and for which providers this is happening most frequently,” Fuglesten Biniek explains. The researchers analyzed about 620,000 claims from 2016. All involved inpatients whose insurance was in-network with the hospital in 37 states and the District of Columbia. Some key findings:

  • Overall, 14.5% of admissions had at least one out-of-network professional claim;
  • States varied widely in the prevalence of out-of-network claims, ranging from 1.7% in Minnesota to 26.3% in Florida;
  • The largest share of out-of-network claims (16.5%) came from anesthesiology;
  • Of the in-network admissions with an independent lab claim, 22.1% of those lab claims were out of network;
  • Emergency medicine accounted for 11% of the out-of-network claims.

“In one sense, the results were not particularly surprising,” says Bill Johnson, PhD, another study co-author. Surprise anesthesiologist bills have received a fair amount of media attention.

“However, the fact that patients can go to an in-network admissions and receive out-of-network care is surprising, in and of itself,” Johnson says. The sheer volume of the surprise bills also was unexpected. “Roughly one in seven in-network admissions had these associated out-of-network claims. This is a striking number,” Johnson says.

Some out-of-network bills cannot be avoided by anyone in the revenue cycle since they involve physician groups external to the hospital. But in-network status with the hospital itself is a different story. Many problems can be avoided if patient access staff find it early. “From a revenue cycle perspective, communication is paramount when patients are having scheduled elective procedures out of network,” Kirby offers. Patients need a full understanding of precisely what it means for them financially. “This would allow patients the opportunity to do some price shopping to see if they could come up with a better price,” Kirby suggests. Arranging a discount is not out of the question. “Healthcare is competitive. Hospitals are strategically trying to attract new patients,” Kirby says. While few consumers would pay sticker price for a new car, they do not realize healthcare costs are not always ironclad.

“If a patient is making a large bulk payment, they most certainly have leverage to negotiate,” Kirby says. “Hospitals are very competitive when it comes to elective surgeries.” MetroHealth’s financial counselors give patients options before they receive services. Kirby suggests this scripting: “Since you realize that you are out of network, and if you are in agreement with paying your out-of-pocket expenses upfront, we would like to offer you a discount of [blank].”

Right when a patient is scheduled, preadmitted, or preregistered, patient access should jump on the opportunity to help the patient avoid surprise bills. “The front end should be trained to watch for out-of-network coverage and advise the patient accordingly,” says Pete Kraus, CHAM, CPAR, FHAM, business analyst for revenue cycle operations at Emory Hospitals in Atlanta.

Still, surprise bills are tough to predict. “Where things get tricky is when physicians order consultations with out-of-network providers,” says Kraus, noting that tests conducted by out-of-network labs also are problematic. “Tracking such contingencies mid-treatment is challenging. There are a lot of moving parts, so to speak.”

The one thing patient access can always offer is education. “Staff can’t be experts on everything pertaining to patient third-party coverage. But they should be comfortable with general concepts,” Kraus says.

Giving patients some specific questions to ask their health insurer is one way patient access can help. “To protect themselves from out-of-network expenses, patients must know enough about their coverage to ask questions of their providers,” Kraus adds.

Of course, surprise bills can come up even with lab test results from providers the plan deems out of network. “It seems all but inevitable that the patient will blame the provider for arcane, hard-to-follow rules by a patient’s insurer,” Kraus says.

Savvy patient access staff can at least inform patients of this possibility in advance.

“This may help avoid a denial or reduction of reimbursement,” Kraus offers. “But the provider will probably get blamed for the surprise bill anyway.”

In dealing with patient complaints about surprise bills, scripting can help somewhat.

“It can assure a uniform response message. But by then it’s too late,” Kraus says. “The front-end proactive approach is essential. Preferably, this happens at the time of scheduling, but certainly when the encounter is preregistered and preauthorized.”


  1. Kennedy K, Johnson W, Fuglesten Biniek J. Surprise out-of-network medical bills during in-network hospital admissions varied by state and medical specialty, 2016. Healthcare Cost Institute. Available at: http://bit.ly/2WlTwO0. Accessed May 3, 2019.