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

Background: The utilization of outpatient (OP) total joint arthroplasty (TJA) is increasing. Although 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 are 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 is a retrospective study of the MarketScan commercial claims database of OP-TJAs (same-day discharge) performed at ASCs or HOPDs from 2007 to 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 OP-TJA patients (58.8% total knee arthroplasty). Utilization of out-of-network facilities significantly decreased over time, from 27.8% of surgeries in 2007 to 9.5% in 2017 (P_trend < .001); however, this was non-linear with a significant increase in 2013-2015 corresponding to rising use of out-of-network ASCs. Patients treated at ASCs were significantly more likely to be out-of-network than those treated at HOPDs (odds ratio 4.88, 95% confidence interval 4.28-5.57, P < .001; odds ratio 7.70, 95% confidence interval 6.42-9.25, P < .001 among the 11,870 patients with in-network surgeons). About 10.4% of patients with in-network surgeons were treated at out-of-network facilities.

Conclusion: Although 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.