Surprise Out-of-Network Bills for Hand and Upper Extremity Trauma Patients

Chao Long, Gongliang Zhang, Kavya K. Sanghavi, Cecil Qiu, Kenneth R. Means, Aviram M. Giladi

Research output: Contribution to journalArticlepeer-review


Purpose: Patients may receive surprise out-of-network bills even when they present to in-network facilities. Surprise bills are common following emergency care. We sought to characterize and determine risk factors for surprise billing in hand and upper extremity trauma patients in the emergency department (ED). Methods: We used IBM MarketScan data to evaluate hand and upper extremity trauma patients who received care in the ED from 2010 to 2017. Our primary outcome was the surprise billing incidence, defined as encounters in in-network EDs with out-of-network claims. We used descriptive and bivariate analyses to characterize surprise billing and used multivariable logistic regression to evaluate independent factors associated with surprise billing. Results: Of 710,974 ED encounters, 97,667 (14%) involved surprise billing. The incidence decreased from 26% in 2010 to 11% in 2017. Mean coinsurance payments were higher for surprise billing encounters and had double the growth from 2010 to 2017 compared to those without surprise billing. Receiving care from different provider types—especially therapists, radiologists, and pathologists, as well as hand surgeons—was associated with significantly higher odds of surprise billing. Transfer to another facility was not significantly associated with surprise billing. Conclusions: Although the incidence of surprise billing decreased, more than 10% of patients treated in an ED for hand trauma remain at risk. Coinsurance for surprise billing encounters increased by twice as much as encounters without surprise billing. Patients requiring services from therapists, radiologists, pathologists, and hand surgeons were at greater risk for surprise bills. The federal No Surprises Act, passed in 2020, targets surprise billing and may help address some of these issues. Clinical relevance: Many hand and upper extremity patients requiring ED care receive surprise bills from various sources that result in higher out-of-pocket costs.

Original languageEnglish (US)
JournalJournal of Hand Surgery
StateAccepted/In press - 2021
Externally publishedYes


  • Hand trauma
  • health policy
  • insurance
  • out-of-network
  • surprise billing

ASJC Scopus subject areas

  • Surgery
  • Orthopedics and Sports Medicine


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