[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.