Out-of-Network Facility Charges for Patients Undergoing Outpatient Total Joint Arthroplasty

Abstract Background The utilization of outpatient(OP) total joint arthroplasty(TJA) is increasing. While many arthroplasty surgeons and hospitals have longstanding agreements with insurance companies, it may take time for ambulatory surgery centers(ASCs) to establish in-network agreements. The purposes of this study were to investigate trends in out-of-network facility charges for OP-TJA, as well as compare rates of out-of-network facilities between ASC and hospital outpatient department(HOPD) OP-TJA. Methods This was a retrospective study of the MarketScan commercial-claims database of OP-TJAs(same-day discharge) performed at ASCs or HOPDs from 2007-2017. Detailed demographic, geographic, operative, insurance, temporal, and financial details were collected. Out-of-network facility utilization was trended over time. Adjusted regressions compared the prevalence of out-of-network facilities between ASCs and HOPDs. Results There were 13,031 patients OP-TJAs (58.8% TKA). Utilization of out-of-network facilities significantly decreased over time, from 27.8% of surgeries in 2007 to 9.5% in 2017 (ptrend Conclusion While the utilization of out-of-network facilities has decreased, over 10% of patients with in-network surgeons face out-of-network facility charges, which may often come as a surprise. Efforts are warranted to reduce the out-of-network facility burden for OP-TJA patients, including accelerating insurance contracting and reviewing patients’ coverage statuses.