NYT: Paying Till It Hurts: Surprise Out of Network Bills From "Assistant" Surgeon
Paying Till It Hurts: Surprise Bills
After Surgery, Surprise $117,000 Medical Bill From Doctor
He Didn’t Know
By ELISABETH ROSENTHAL SEPT. 20, 2014
Peter Drier was billed by an assistant surgeon he did not
know was on his case.
Before his three-hour neck surgery for herniated disks in
December, Peter Drier, 37, signed a pile of consent forms. A bank technology
manager who had researched his insurance coverage, Mr. Drier was prepared when
the bills started arriving: $56,000 from Lenox Hill Hospital in Manhattan,
$4,300 from the anesthesiologist and even $133,000 from his orthopedist, who he
knew would accept a fraction of that fee.
He was blindsided, though, by a bill of about $117,000
from an “assistant surgeon,” a Queens-based neurosurgeon whom Mr. Drier did not
recall meeting.
“I thought I understood the risks,” Mr. Drier, who lives
in New York City, said later. “But this was just so wrong — I had no choice and
no negotiating power.”
In operating rooms and on hospital wards across the
country, physicians and other health providers typically help one another in
patient care. But in an increasingly common practice that some medical experts
call drive-by doctoring, assistants, consultants and other hospital employees
are charging patients or their insurers hefty fees. They may be called in when
the need for them is questionable. And patients usually do not realize they
have been involved or are charging until the bill arrives.
The practice increases revenue for physicians and other
health care workers at a time when insurers are cutting down reimbursement for
many services. The surprise charges can be especially significant because, as
in Mr. Drier’s case, they may involve out-of-network providers who bill 20 to
40 times the usual local rates and often collect the full amount, or a
substantial portion.
“The notion is you can make end runs around price
controls by increasing the number of things you do and bill for,” said Dr.
Darshak Sanghavi, a health policy expert at the Brookings Institution until
recently. This contributes to the nation’s $2.8 trillion in annual health
costs.
Insurers, saying the surprise charges have proliferated,
have filed lawsuits challenging them. In recent years, unexpected
out-of-network charges have become the top complaint to the New York State
agency that regulates insurance companies. Multiple state health insurance
commissioners have tried to limit patients’ liability, but lobbying by the
health care industry sometimes stymies their efforts.
“This has gotten really bad, and it’s wrong,” said James
J. Donelon, the Republican insurance commissioner of Louisiana. “But when you
try to address it as a policy maker, you run into a hornet’s nest of financial
interests.”
In Mr. Drier’s case, the primary surgeon, Dr. Nathaniel
L. Tindel, had said he would accept a negotiated fee determined through Mr.
Drier’s insurance company, which ended up being about $6,200. (Mr. Drier had to
pay $3,000 of that to meet his deductible.) But the assistant, Dr. Harrison T.
Mu, was out of network and sent the $117,000 bill. Insurance experts say
surgeons and assistants sometimes share proceeds from operations, but Dr.
Tindel’s office says he and Dr. Mu do not. Dr. Mu’s office did not respond to
requests for comment.
The phenomenon can take many forms. In some instances, a
patient may be lying on a gurney in the emergency room or in a hospital bed,
unaware that all of the people in white coats or scrubs who turn up at the
bedside will charge for their services. At times, a fully trained physician is
called in when a resident or a nurse, who would not charge, would have
sufficed. Services that were once included in the daily hospital rate are now
often provided by contractors, and even many emergency rooms are staffed by
out-of-network physicians who bill separately.
Patricia Kaufman’s bills after a recent back operation at
a Long Island hospital were rife with such charges, said her husband, Alan, who
spent days sorting them out. Two plastic surgeons billed more than $250,000 to
sew up the incision, a task done by a resident during previous operations for
Ms. Kaufman’s chronic neurological condition.
In the days after the operation, “a parade of doctors
came by saying, ‘How are you,’ and they could be out of network or in network,”
Mr. Kaufman said. “And then you get their bills. Who called them? Who are
they?”
Doctors’ offices often pursue patients for payment. Ms.
Kaufman’s insurer paid about $10,000 to the plastic surgeons, who then sent a
bill for the remainder. The couple, of Highland Park, N.J., refused to pay.
When insurers intervene in a particular case, they say
they have limited ability to fight back. Insurance examiners “are not in the
room on the day of surgery to see the second surgeon walk into the room or why
they were needed,” said Clare Krusing, a spokeswoman for America’s Health
Insurance Plans, an industry group. And current laws do not require hospitals
that join an insurance network to provide in-network doctors, labs or X-rays,
for example.
When out-of-network physicians perform hospital procedures,
hefty charges can be added to medical bills. Insurers often pay the full amount
or large portions, which provides an incentive for doctors to include
out-of-network colleagues.
So sometimes insurers just pay — to protect their
customers, they say — which encourages the practice. When Mr. Drier complained
to his insurer, Anthem Blue Cross Blue Shield, that he should not have to pay
the out-of-network assistant surgeon, Anthem agreed it was not his
responsibility. Instead, the company cut a check to Dr. Mu for $116,862, the
full amount.
Unexpected Fees
When Mr. Drier agreed to surgery in December, he was not
in a good position to bargain or shop around. Several weeks earlier, he had
woken up to excruciating pain in his upper back and numbness and weakness in
two fingers of his left hand, which persisted. A scan showed that one of the
disks that normally serve as cushions between vertebrae was herniated and
pushing on a nerve. With a busy job and social life, he was living on
painkillers.
The rate of spinal surgery in the United States is about
twice that in Europe and Canada, and five times that in Britain, said Dr.
Richard A. Deyo of Oregon Health and Science University, who studies
international comparisons. Studies are limited but have generally concluded
that after two years, patients who have surgery for disk problems do no better
than those treated with painkillers and physical therapy — although the pain,
which can be debilitating, resolves far more rapidly with surgery.
The United States has more neurosurgeons per capita than
almost any other developed country, and they compete with orthopedists for
spinal surgery. At the same time, Medicare and private insurers have reduced
payments to surgeons. The average base salary for neurosurgeons decreased to
$590,000 in 2014 from $630,000 in 2010, according to Merritt Hawkins, a
physician staffing firm.
To counter that trend, some spinal surgeons have turned
to consultants — including a Long Island company called Business Dynamics RCM
and a subsidiary, the Business of Spine — that offer advice on how to increase
revenue through “innovative” coding, claim generation and collection services.
Some strategies used by surgeons, including billing large
amounts for a second surgeon in the room or declaring an operation an
emergency, raise serious questions. The indications for immediate spinal
surgery, such as loss of bladder function or rapidly progressive paralysis, are
rare. But insurers are more likely to reimburse a hospital or surgeon with whom
they do not have a contract if a case is labeled an emergency.
Mark Sullivan, 46, of New Jersey, went to an emergency
room last year with excruciating lower back pain and leg weakness. He was in
the operating room less than 24 hours later. “The surgeon stood at the foot of
my bed and said, ‘You need surgery; you won’t walk out of the hospital,’ ” he
recalled.
Mr. Sullivan’s emergency admission made it easier for an
out-of-network surgeon to perform the operation and bill $29,000. The insurer
paid $9,500, and Mr. Sullivan paid about $580, as required by his plan. When the
doctor’s billing office pursued Mr. Sullivan for the balance of the bill and
even threatened to turn his account over to collection, he agreed to file an
appeal with his insurer for additional payment, but he refused to pay more
himself.
A Last-Minute Surprise
Mr. Drier’s concern about extra charges began even during
his preoperative physical. The hospital sent his blood tests to an
out-of-network lab and required him to have an echocardiogram (eventually
billed for $950), even though he had no cardiac history. (The American Society
of Echocardiography discourages such testing for patients with no known heart
problems.)
His worries escalated as he lay prepped for the operating
room on the morning of his surgery. A technician from a company called
Intraoperative Monitoring Service L.L.C. asked him to sign a financial consent
form, noting that the company did not accept Blue Cross Blue Shield plans, so
he would be required to pay the bill himself. The monitoring had been ordered
by his surgeon and is considered essential for the type of neurosurgery he was
having, to make sure delicate nerves are not damaged as they are manipulated.
“I demanded to know the price, and when he said he didn’t
know, I made him call,” Mr. Drier recalled. When the technician said it would
be $500 plus an hourly rate, Mr. Drier negotiated it down to $300.
In the operating room, he underwent a procedure called
spinal fusion, in which the surgeons removed two herniated disks that were
impinging on nerves, and inserted some bone graft as well as plates and screws
to stabilize the spine. On his hospital bill, Mr. Drier noted charges for three
implants, a total of about $10,400, as well as for two surgical screws billed
at $2,470 and $3,990 — expensive for hardware, he thought, but his insurer paid
the full amount.
The biggest surprise was the bill from Dr. Mu, the
assistant surgeon. Fusions generally require a second trained pair of hands,
but those can be provided by a resident or a neurosurgical nurse or physician
assistant employed by the hospital, for whom there is no additional charge. The
operative record for Mr. Drier’s surgery states that no qualified resident was
available.
Dr. Mu is the chief of neurosurgery at Jamaica Hospital
Medical Center in Queens, though he sometimes operates at other hospitals.
According to a database that tracks hospital admissions in New York State, most
operations he performs at Jamaica involve emergency surgery on Medicaid
patients, often victims of trauma — a challenging but probably not very
lucrative practice.
One insurer, Aetna, is in court with Dr. Mu’s
private-practice group, NeuroAxis Neurosurgical Associates of Kew Gardens,
Queens. NeuroAxis sued to recover higher payments for its out-of-network
assistant surgeons; Aetna says the practice’s fees for those surgeons are
excessive. J. Edward Neugebauer, chief litigation officer at Aetna, said the
company had also sued an in-network neurosurgeon on Long Island who always
called in an out-of-network partner to assist, resulting in huge charges. The
surgeons shared a business address.
Surgeons from other specialties also team up: After
Gunther Steinberg of Portola Valley, Calif., had a needle biopsy of an eye
lesion in 2010, he discovered that his insurer had paid about $10,000 to the
eye surgeon who performed the outpatient procedure and $10,700 to a second
ophthalmologist in the room.
“The idea of having an assistant in the O.R. has become
an opportunity to make up for surgical fees that have been slashed,” said Dr.
Abeel A. Mangi, a professor of cardiac surgery at Yale, who said the practice
had become commonplace. “There’s now a whole cadre of people out there who do
not have meaningful appointments as attending surgeons, so they do assistant
work.”
In Mr. Drier’s case, each surgeon billed for each step of
the procedure. Dr. Tindel billed $74,000 for removing two disks and an
additional $50,000 for placing the hardware that stabilized Mr. Drier’s spine.
Dr. Mu billed $67,000 and $50,000 for those tasks.
If the surgery had been for a Medicare patient, the assistant
would have been permitted to bill only 16 percent of the primary surgeon’s fee.
With current Medicare rates, that would have been about $800, less than 1
percent of what Dr. Mu was paid.
Visitors Who Bill
Unexpected fees are routinely generated outside the
operating room as well. On the wards, a dermatologist may be called in to
examine a rash and perform an expensive biopsy. The person in scrubs who walks
a patient to a bathroom for the first time after hip surgery may turn out to be
a physical therapist billing $400.
Mr. Sullivan, who had the emergency back surgery,
discovered charges from more than 10 providers in the 48 hours after his
operation. (The surgery involved simply trimming a herniated disk in his lower
back.) He wrote to various doctors to dispute bills, saying, “I was admitted to
Overlook Hospital from Nov. 26-27, 2013, and I have received numerous invoices
for procedures that were never done, by physicians that never treated me.”
He was puzzled by $679 in occupational therapy charges
involving the delivery of a device to help him put on his socks, which he never
used. He was irate about charges from a group of hospital-based primary care
physicians from Inpatient Medical Associates, who visited him briefly once a
day and billed close to $1,000 in out-of-network costs.
Mark Sullivan, 46, of New Jersey, received a hospital
bill that included charges for occupational therapy, which he did not realize
had occurred.
Healthy surgical patients typically do not need a general
doctor; an anesthesiologist clears them for surgery. Mr. Sullivan noted that if
he had needed an internist, he would have called his own, who is in his
insurance network and whose office is just down the block.
Dr. Mangi, the Yale cardiac surgeon, said hospitals often
encouraged extra visits for both billing and legal reasons. He said he was
required to request a physical therapy consult before each discharge, for
example, even if he felt there was no need.
“You can cut fees, but institutions find ways” to make
the money back, he said. “There’s been a mushrooming industry of mandatory
consultants for services that neither doctors nor patients want.”
A Possible Remedy
For months, Mr. Drier stewed over what to do with the
$117,000 check Anthem Blue Cross had sent him to pass on to Dr. Mu, refusing to
sign over a payment he considered “outrageous and immoral.” He worried that
such payments could drive up premiums at his employer.
In the past few years, some insurers have filed lawsuits
and sought injunctions to prevent providers from going after their clients for
payment of unexpected medical bills. Dr. Scott Breidbart, chief medical officer
at Empire Blue Cross Blue Shield, part of the same parent company that covers
Mr. Drier, said that it had not taken that route, but that in some situations
it had refused to do further business with in-network surgeons who repeatedly
called in out-of-network assistants.
A New York State law that will take effect in March — one
of a few nationally — will offer some protection against many surprise charges
and require more advance disclosure from doctors and hospitals on whether their
services are covered by insurance. It states, for example, that patients are
not responsible for unforeseen out-of-network charges beyond what they would
have paid in-network. It directs insurers and hospitals to negotiate any
further payment or enter mediation.
In many other countries, such as Australia — where, as in
the United States, people often rely on private insurance — it is seen as a
patient’s right to be informed of out-of-pocket costs before hospitalization,
said Mark Hall, a law professor at Wake Forest University.
Peter Drier
“I couldn’t beat the medical billing administrators that
knew how to say the right things and never said anything wrong and knew the
laws backwards.”
Publish Date
September 20, 2014.
Mr. Drier tried to negotiate with the surgeons to divvy
up the $117,000 payment in a way he believed was more fair; he liked Dr. Tindel
and felt he was being underpaid. Mr. Drier’s idea, he wrote in an email, was to
settle on “a reasonable fee for both the surgeon and assistant and return the
rest of the check to the insurance company/employees” of his company.
But in July, he received a threatening letter from Dr.
Mu’s lawyer noting that he had failed to forward the $117,000 check. So he sent
it along, with regret.
For a continuing conversation about health care costs and
pricing in the United States, please join our Facebook group, Paying Till It
Hurts.
A version of this article appears in print on September
21, 2014, on page A1 of the New York edition with the headline: After Surgery,
$117,000 Bill for Doctor He Didn’t Know.
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