ArticleOtolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery2025
Out-of-Pocket Costs and Surprise Billing in Otolaryngology: A National Database Analysis.
Article in Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery, 2025. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
objectiveTo evaluate out-of-pocket (OOP) costs and surprise billing (unexpected charges from out-of-network providers) in otolaryngology. STUDY
designRetrospective cohort study.
settingNational commercial claims database.
methodsMerative 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.
resultsOf 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).
conclusionCommon 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.
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