Curious Medical Billing Situation

[jyl]

If you are interested in - better yet, knowledgeable about - medical billing, perhaps you might read this article and explain to me why this practice makes sense.

http://www.nytimes.com/2014/09/21/us/drive-by-doctoring-surprise-medical-bills.html

By this practice, I mean doctors who you don't know and who aren't in-network to your insurance, coming in to consult on your case, without your consent or in this case your knowledge, and billing you for a large fee.

Basically this guy had a spinal fusion, his surgeon brought in a second surgeon to assist, the second surgeon billed $117,000 and the patient had to pay it, or rather his insurer paid it. The patient had never heard of the second surgeon, was unconscious when the doctor arrived, never signed any paperwork directly with that doctor.

[Bugsinrugs]

Our wonderful health care system at work. Doctors figuring a way to make money above what they get from Medicare.

[Noah930]

That article is woefully inadequate on discussing the issues surrounding this type of over billing event. And most likely purposefully so, to push a particular editorial agenda. Though that's my personal bias, which is more of an admission than you'd get from the media.

First of all, the laws regarding medical billing vary state-by-state. So even when people write based on personal experience, outcomes will differ based upon the location involved.

...

[Noah930]

...

Lots of issues involved here: provider networks, variations in individual contracts, balance billing, customary/regional billing practices, and plain old ethics.

Insured People will often pick primary providers within their network, for obvious financial considerations. But it gets complicated when a team approach is necessary for care. You may pick an internist or surgeon partially I based upon whether or not they're within network, but what happens when you need a lab, or x-rays, an anesthesiologist, or a facility like a hospital or surgery center? Sometimes it's like getting planets to align, finding a surgeon, a lab, a radiologist, a pathologist, a surgery center, and an anesthesiologist all within your network. If any of those planets don't align, you stand the proposition of a billing surprise. And even in my limited career-span, I have seen that getting worse with time, not better. These were trends that started even before Obamacare, though Obamacare may have hastened this progression, IMO.

And there seem to be certain specialties that are frequently out-of-network: ER docs, anesthesiologists, radiologists, and pathologists. Locally, even hospitals (as in, the physical plant of the hospital itself and the ER) are terminating contracts with insurers. It's hard to negotiate or shop around for a better deal when you're lying on your back in distress on a gurney.

[Noah930]

You may find a surgeon within network, but how about the hospital or surgery center where the procedure's to be done, or the anesthesiologist who's putting you to sleep? The surgeon may have some control over obtaining privileges at a facility that's within network (though unless he/she owns the facility, that facility may or may not be within network the following year). And there are a myriad of networks, individual to each insurer. But the surgeon certainly has no control over the network affiliations of the anesthesiologist. A surgeon has no more control over who the anesthesiologist is going to be on any particular day, than a catcher does over who the starting pitcher will be for a game. A surgeon and the anesthesiologist are two separate businesses; they may work in collaboration, but one can't make contractual decisions for the other.

[Noah930]

But back to jyl's original post. It is not uncommon for an assistant surgeon (which is different than a co-surgeon) to be involved. The patient often does not meet the assistant surgeon in the office, but rather just on the day of the surgery. It is often the case that if an assistant is involved, the primary surgeon makes a mention of it beforehand (either in the office or on the date of surgery). It's not something that surgeons make a big deal about--like if there was a medical/nursing student or other observer in the OR. It's often mentioned in passing. Patient's usually don't make a big fuss about it. I don't think there's a law that stipulates a surgeon has to inform a patient of an assistant, and there's no additional paperwork that has to be compiled that I know of. In this case, the surgeon may or may not have mentioned it to the patient. Even if the surgeon did, it would not be surprising if the patient did not recall the event.

(Incidentally and anecdotally, an anesthesiologist once told me a story of how his billed was rejected by the patient because the patient did not recall meeting him. To a certain degree, that was probably because the anesthesiologist did a good job and kept the patient sedated and comfortable, which usually includes administering medications that work as amnestics, which cloud a patient's memory of the surgical--including pre- and post--events. This was despite the fact that the anesthesiologist clearly filled out the paperwork to document his presence before, during, and after the case. Anesthesiologists are required, for example, to document the vital signs every 5 minutes throughout a surgery. No one is going to do that tedious task for the anesthesiologist during the surgery. The insurer sided with the patient and refused to pay the anesthesiologist.)

Usually the assistant surgeon is within network, so that part's not an issue. This was a sneaky thing by the assistant surgeon in this case, IMO. And while there's no over-riding law on how much an assistant surgeon can bill, usually the insurance company stipulates, in its contract with the doctor, how much an assistant can bill. The article mentioned that in the case of Medicare, it's 16% of the surgeon's fee. In California for worker's comp, for example, I think it's 20%. So if the surgeon collected $1000 for the surgery, then (using Medicare as the example) the assistant should collect 16% of that, $160. But heck, if the contract between doctor and insurance company read 80%, then the assistant can bill $800. In this case, there was no contract between insurance company and assistant doctor, so that's where the problem lay. If the assistant was an NP or PA (working under the license of the surgeon), then the contract between surgeon and insurance company is the one that is in effect. In personal injury/litigated cases I've reviewed, I've seen assistant surgeons bill 80% of the surgeon's fee. Because there is no contract in that situation, as legal/financial liability has not yet been established.

The other issue is that you can't just stick an assistant into the OR for every case. You could, but there is not the expectation of reimbursement. That's effectively established by Medicare billing rules, which most insurance companies follow. Effectively, for "easy" procedures that a surgeon should be able to accomplish by himself, insurance companies will not pay for an assistant. Often, spine cases like the one in this instance are allowed to have an assistant. Usually, that's something that's established between surgeon and insurance company before the surgery, because usually the surgeon has to clear it with the insurance company that the insurer will authorize (and pay for) the surgery. And often the insurance company will ask if an assistant will be present. I've never been in the situation of what happens, though, if the surgeon does not tell the insurance company that there will be an assistant, yet there is one on the day of the procedure.

So it's not illegal or unusual to have an assistant in a spinal fusion surgery. But the billing practice is quite unusual in this instance.

Even if the insurance company paid it, if the patient is pissed off enough (and for $100K I would be), the patient can write a complaint to the state medical board. Because the state medical board can do whatever the F it wants. It can make up its own rules as it goes along. And it doesn't even have to follow the rules that it's written down in it's own guidelines. So even if all this assistant billing issue was considered legal, there's certainly an issue of ethics involved. And the state medical board can sanction the doc (or even pull his license--though that's really unlikely in this case) in whatever fashion it feels is appropriate.

[Noah930]

Originally Posted by peteremsley

I'm really interested in this, but unfortunately not knowledgeable at all.

I am in the same situation, though on a much smaller scale. I was very careful to stay in network for my broken kneecap surgery, but have ended up with a bill for around $2k from an anesthesiologist who just showed up on the day. Just got the bill a few weeks back. Not really sure how to proceed, but I'm not writing a check until I've dug around a bit.

Realistically, could you have undergone kneecap surgery without the anesthesiologist?

It's OK for you to never have met the anesthesiologist until the day of surgery, nor to have any follow-up contact with him/her afterwards. But I'm guessing that's not what you're contesting.

It's not uncommon for the anesthesiologist to be out-of-network. After all, if they feel that your insurance company pays too little for what they do, why should they have to sign a contract with said insurer? And given the myriad of insurers out there, isn't not practical to schedule a surgery day where the surgeon and anesthesiologist (two separate businesses) are all on matching networks.

But if you feel the bill is out of proportion to the service provided, then you can try to negotiate an appropriate rate with the anesthesiologist. Find out what he/she would have been paid had he been within network and see if he/she will take it. Call up your insurance company and ask them (with the diagnosis and procedure codes in hand.) What would Medicare have paid? (Though I don't know who you're going to ask to figure out the answer to that question.)

Figure out if your state allows for balance billing. That's where the patient is liable for any part of the bill that the insurance company won't pay. Hopefully for you, the answer is no.

Find out if there's any state stipulation that the facility has to provide an anesthesiologist within network. For example, when the surgery center where I work was recertified by either Medicare or Blue Cross a few years back, the facility had to ensure that there would always be a Medicare/Blue Cross anesthesiologist on staff. That was a condition of recertification. See if that's true in your state. And if it is, push the anesthesiologist to accept whatever your insurer would have paid (or at least try to negotiate something in between).

But in the end, and again this depends on state laws, if the anesthesiologist is out-of-network and has billed $2K, you might be legally liable for $2K.

[jyl]

Seems like a patient should be able to negotiate an all-in price for a surgery like that, and refuse to pay charges not expressly agreed to.

[john70t]

If the auto repair industry billed that way...

[Noah930]

Originally Posted by jyl

Seems like a patient should be able to negotiate an all-in price for a surgery like that, and refuse to pay charges not expressly agreed to.

I typed a response, but it wouldn't post. In short, it's not that simple. On the date of surgery, you have several different businesses. **Separate** businesses. The surgeon. The anesthesiologist. The facility. And depending, there could be a pathologist, an implant manufacturer (i.e. plates & screws), a provider for post-op durable medical equipment (DME) like ice machines, etc. They're all different businesses, so they all bill separately.

I get the gyst of what you're typing, jyl, from the consumer side of things. In cosmetic surgery there's usually a single bill, for example. So it's not an impossibility to arrange for a simpler billing model. But at the same time, in cosmetic surgery, everyone knows what everyone's getting paid. The surgeon, anesthesiologist, and facility have predetermined (and already received) what they're getting. With insurance, no one knows what they're getting until they get paid several months later. (Despite what the contracts stipulate.) And insurance (who sets the rules on this stuff) has determined that each business bills separately for services provided. There's no code for any all-inclusive payment, only codes for individual services provided. If you don't like the way billing is confusing, it's not the providers promoting the system; they don't write the rules.

[aap1966]

Originally Posted by jyl

.................. the second surgeon billed $117,000....

I wish I was an American orthopod................

[emcon5]

Originally Posted by Noah930

I typed a response, but it wouldn't post. In short, it's not that simple. On the date of surgery, you have several different businesses. **Separate** businesses. The surgeon. The anesthesiologist. The facility. And depending, there could be a pathologist, an implant manufacturer (i.e. plates & screws), a provider for post-op durable medical equipment (DME) like ice machines, etc. They're all different businesses, so they all bill separately.

And this, right here, is the problem.

[Tobra]

Originally Posted by aap1966

I wish I was an American orthopod................

Almost certainly a neurosurgeon.

As previously stated, a fairly complex issue.

[john70t]

Originally Posted by emcon5

And this, right here, is the problem.

I suspect that even with a reasonable justified billing for a procedure covering only costs and moderate income, the insurance comps still try to negotiate a lower price. Knowing this, medicine charges the max for everything.

Both have demanding shareholders and expensive execs.

The consumer/citizen, already in debt and overstretched, is on the receiving end of both practices with little recourse.Medical Bills Are the Biggest Cause of US Bankruptcies: Study

[Don Ro]

In my room, post-op quad by-pass, I was visited by two different ladies wanting me to sign-off for in-home care for a week's worth.
I said I'd think about that. Well, one woman kept coming in with a different argument each time but insisting that it would be free - probably 4 times.
The last time she came in I was getting annoyed at her insistence.
She, herself, got upset with me..."Have you heard me? It's FREE to you!"...and stormed out.
Both women were reps from a company that gets paid via Medicare and they wanted the business.
It's a feeding frenzy out there when it comes to taxpayer money - everyone wants their share.
.
I recovered on my own at home quite nicely w/o any assistance.