Surprise hospital billing. It pays to know your state laws.

Izzy Benasso was playing a casual game of tennis with her father on a summer Saturday when she felt her knee pop. She had torn a meniscus, one of the friction-reducing pads in the knee, locking it in place at a 45-degree angle.

Although she suspected she had torn something, the 21-year-old senior at the University of Colorado Boulder had to endure an anxious weekend in July 2019 until she could get an MRI that Monday.

"It was kind of emotional for her," said her father, Steve Benasso. "Just sitting there thinking about all the things she wasn't going to be able to do."

At the UCHealth Steadman Hawkins Clinic Denver, the MRI confirmed the tear, and she was scheduled for surgery on Thursday. Her father, who works in human resources, told her exactly what to ask the clinic regarding her insurance coverage.



Steve had double-checked that the hospital; the surgeon, Dr. James Genuario; and Genuario's clinic were all within her Cigna health plan's network.

"We were pretty conscious going into it," he said.

Isabel met with Genuario's physician assistant on Wednesday, and the following day underwent a successful meniscus repair operation.

"I had already gotten a ski pass at that point," Isabel said. "So that was depressing." But she was heartened to hear that with time and rehab she would get back to her active lifestyle.

Then a letter arrived that portended bills to come.

The patient: Izzy Benasso, a 21-year-old college student covered by her mother's Cigna health plan.

The total bill: $96,377 for the surgery was billed by the hospital, Sky Ridge Medical Center in Lone Tree, Colo., part of HealthONE, a division of the for-profit hospital chain HCA. It accepted a $3,216.60 payment from the insurance company, as well as $357.40 from the Benassos, as payment in full. The surgical assistant billed separately for $1,167.

Service provider: Eric Griffith, a surgical assistant who works as an independent contractor.

Medical service: Outpatient arthroscopic knee surgery to repair the meniscus.

What gives: The Benassos had stumbled into a growing trend in health care: third-party surgical assistants who aren't part of a hospital staff or a surgeon's practice. They tend to stay out-of-network with health plans, either accepting what a health plan will pay them or billing the patient directly. That, in turn, is leading to many surprise bills.

Study: 1 In 5 Patients Gets A Surprise Medical Bill After Surgery
SHOTS - HEALTH NEWS
Study: 1 In 5 Patients Gets A Surprise Medical Bill After Surgery
Even before any other medical bills showed up, Izzy received a notice from someone whose name she didn't recognize.

"I'm writing this letter as a courtesy to remind you of my presence during your surgery," the letter read.

It came from Eric Griffith, a Denver-based surgical assistant. He went on to write that he had submitted a claim to her health plan requesting payment for his services, but that it was too early to know whether the plan would cover his fee. It didn't talk dollars and cents.

Steve Benasso said he was perplexed by the letter's meaning, adding: "We had never read or heard of anything like that before."

Surgical assistants are not medical doctors, but serve as an extra set of hands for surgeons, allowing them to concentrate on the technical aspects of the surgery. Oftentimes other surgeons or physician assistants — or, in teaching hospitals, medical residents or surgical fellows — fill that role at no extra charge. But some doctors rely on certified surgical assistants, who generally have an undergraduate science degree, complete a 12- to 24-month training program and then pass a certification exam.

Surgeons generally decide when they need surgical assistants, although the Centers for Medicare & Medicaid Services maintains lists of procedures for which a surgical assistant can and cannot bill. Meniscus repair is on the list of allowed procedures.
A Sky Ridge spokesperson said that it is the responsibility of the surgeon to pre-authorize the use and payment of a surgical assistant during outpatient surgery, and that HealthOne hospitals do not hire surgical assistants. Neither the assistant nor the surgeon works directly for the hospital. UC School of Medicine, the surgeon's employer, declined requests for comment from Genuario.

Karen Ludwig, executive director of the Association of Surgical Assistants, estimates that 75% of certified surgical assistants are employed by hospitals, while the rest are independent contractors or work for surgical assistant groups.

"We're seeing more of the third parties," said Dr. Karan Chhabra, a surgeon and health policy researcher at the University of Michigan Medical School. "This is an emerging area of business."

And it can be lucrative: Some of the larger surgical assistant companies are backed by private equity investment. Private equity firms often target segments of the health care system where patients have little choice in who provides their care. Indeed, under anesthesia for surgery, patients are often unaware the assistants are in the operating room. The private equity business models include keeping such helpers out-of-network so they can bill patients for larger amounts than they could negotiate from insurance companies.



Surgical assistants counter that many insurance plans are unwilling to contract with them.

"They're not interested," said Luis Aragon, a Chicago-area surgical assistant and managing director of American Surgical Professionals, a private equity-backed group in Houston.

Chhabra and his colleagues at the University of Michigan recently found that 1 in 5 privately insured patients undergoing surgery by in-network doctors at in-network facilities still receive a surprise out-of-network bill. Of those, 37% are from surgical assistants — tied with anesthesiologists as the most frequent offenders. The researchers found 13% of arthroscopic meniscal repairs resulted in surprise bills, at an average of $1,591 per bill.

Colorado has surprise billing protections for consumers like the Benassos who have state-regulated health plans. But state protections don't apply to the 61% of American workers who have self-funded employer plans. Colorado Consumer Health Initiative, which helps consumers dispute surprise bills, has seen a lot of cases involving surgical assistants, said Adam Fox, director of strategic engagement.

Resolution: Initially, the Benassos ignored the missive. Izzy didn't recall meeting Griffith or being told a surgical assistant would be involved in her case.

But a month and a half later, when Steve logged on to check his daughter's explanation of benefits, he saw that Griffith had billed the plan for $1,167. Cigna had not paid any of it.

Realizing then that the assistant was likely out-of-network, Steve sent him a letter saying "we had no intention of paying."

Griffith declined to comment on the specifics of the Benasso case but said he sends letters to every patient so no one is surprised when he submits a claim.

"With all the different people talking to you in preop, and the stress of surgery, even if we do meet, they may forget who I was or that I was even there," he said. "So the intention of the letter is just to say, 'Hey, I was part of your surgery.' "

After KHN inquired, Cigna officials reviewed the case and Genuario's operative report, determined that the services of an assistant surgeon were appropriate for the procedure and approved Griffith's claim. Because Griffith was an out-of-network provider, Cigna applied his fee to Benasso's $2,000 outpatient deductible. The Benassos have not received a bill for that fee.

Griffith says insurers often require more information before determining whether to pay for a surgical assistant's services. If the plan pays anything, he accepts that as payment in full. If the plan pays nothing, Griffith usually bills the patient.

The takeaway: As hospitals across the country restart elective surgeries, patients should be aware of this common pitfall — and realize it's a fee they may have no recourse but to pay if their state doesn't have protections against surprise billing.

Chhabra said he's hearing more anecdotal reports about insurance plans simply not paying for surgical assistants, which leaves the patient stuck with the bill.

Chhabra said patients should ask their surgeons before surgery whether an assistant will be involved and whether that assistant is in-network.

"There are definitely situations where you need another set of hands to make sure the patient gets the best care possible," he said. But "having a third party that is intentionally out-of-network or having a colleague who's a surgeon who's out-of-network — those are the situations that don't really make a lot of financial or ethical sense."

LINK: https://www.npr.org/sections/h...ical-assistant-leads

THE LINK ALSO LEADS TO A DETAILED EOB{EXPLANATION OF BENEFITS}

I ran into the same this with my knee surgery in 2009.

Made sure to choose an orthopedic surgeon who was in network. He operates at two different hospitals, so I made sure to choose the hospital that was in network.

Then, when I got the bill, I discovered that while the surgeon and the hospital were in network, the anesthesiologist that was used for the surgery (over which I had no control/choice) was out of network.

Ended up costing me several thousand dollars.

Maybe patients need to start requesting signatures from the professionals the same as they request them from us.

Perhaps a form that the doctor signs that says he, the facility he's operating out of, any other parties he requests be present, and any of the supplies he uses are all covered by your plan. Any bills that are not are their responsibility.

I don't understand how it's legal to bill after the fact and make up a price after the service has already been provided when you have no way to control what is being billed for. In no other service industry that I know of can you not provide an estimate before the service.

The best approach is to ask ALL the questions upfront. Of course that is not always possible, but you should give it a try. The other deal is the hospital is IN NETWORK but NONE of the ER doctors are. I got caught in this one. Some hospitals contract out their ER services to companies such as TEAM HEALTH. Insurance then pays out of network rates. Often it is applied to the deductible and you owe the balance.

Zero sympathy for the peeps who go into these fields knowing full well that they'll have resistance getting their invoices paid due to the strategy via 3rd party 'surprise' billing.

Ultimately the patient / customer / little guy takes it in the end.

I had my knee sx and verified it was covered by the hospital and dr I used. When I was in recovery, I received a call setting me up for rehab. Went to 3 sessions before they told me I wasn’t covered by my insurance at the rehab facility the dr. I used was associated with.
It’s not the doc, it’s not the assistant, it’s the fricking insurance company. The others are just trying to their job and get paid for their work. The insurance company is the one yanking the chain.

quote:

Originally posted by RogueJSK: Then, when I got the bill, I discovered that while the surgeon and the hospital were in network, the anesthesiologist that was used for the surgery (over which I had no control/choice) was out of network.

We've been burned twice by this. First one was years ago, and due to my incorrect assumption that everyone working inside an in-network facility would bill the insurance as in-network. The second one? I did my due diligence and made damn sure the specific anesthesiologist was in-network. Turns out he was, but his nurse anesthetist wasn't.

For planned elective procedures, I have now become the biggest pain in the ass of surgical providers and facilities prior to surgery. If they cannot or will not send a return email that confirms the services they will provide are in network, I start hounding them with phone calls and follow-on emails. I document every phone call and email, then I make contact with my health insurance benefit advocate to pass on the documentation. On two occasions my insurance company has covered me for out-of-network charges based on their "due diligence" policy. This policy is not guaranteed or even well defined, but it seems to be based on sufficient documentation of trying to find out if a specific individual is in-network or not.

So ask your health care company if they they have a benefit advocate who can get involved prior to surgery. My health care advocate is very good about putting the squeeze on the intended providers to give an answer prior to the medical procedure. She's a bulldog when it comes to this.

"But what about emergency room services?" you may be asking. Well, I have a plan if I'm coherent, not in excruciating pain and can communicate. I intend to inform everyone who walks in the room that unless they are willing to accept in-network payment from Blue Cross, they do not have permission to touch me. It may not have any legal clout, but the statement will have been made for them to consider and for any future discussions of out-of-network payments.

I'm normally a calm and collected individual, but surprise out-of-network billing has become one of my few hot buttons. This practice of hiding out-of-network providers in an in-network facility is dishonest and shows a lack of business ethics by the health facility.

My wife is an RNFA of 30 years working for 1 surgeon for the 25 years before retirment.
Because she was in the office doing clinical when not in surgery and conducting pre-op briefings all patients were required to pay her fee upfront. Simple and no surprise billings. Maybe the disconnect between the doctor’s office and an FA not in the drs office is the source of poor communication.

 
I have had that happen with several surgeries, including knee replacement. The assistant was not Medicare certified. They (the assitant's company) tried billing me direct a couple of times. I called them up, and they are aware of the problem. They say they try billing because some supplements will pick up part of their bill (mine won't). They told me just to ignore the two bill attempts, and after that fails for them, they just write it off.
 
They do have assistants who are certified, and they use those whenever they can.

Happened to me once, fought it for a year, got sent to collections, paid the bill, then got issued a refund check eventually. What a PITA. All insurance matters were 'figured' before the surgery, and I paid in advance of the surgery with the center saying they'd accept whatever payment they received for out of network stuff. Still tried to screw me.

quote:

Originally posted by Tailhook 84:

I'm normally a calm and collected individual, but surprise out-of-network billing has become one of my few hot buttons. This practice of hiding out-of-network providers in an in-network facility is dishonest and shows a lack of business ethics by the health facility.

This point is pretty much what I was driving at, Tailhook put it more succinctly.

I'm a mechanic & not in the health-care field, & it may be light-years apart but I can't imagine going into a billable job for a customer knowing that I'm depending on a sub-contractor that the customer never signed off on & who'll submit demand for payment after the fact.

The sub could eventually try to get a lien filed against the property if customer doesn't pay up but those kind of shenanigans would be counter-productive in the long run for the sub / primary contractor.

This message has been edited. Last edited by: soflaac,

Wouldn't it be nice if you could put a 'click-wrap' agreement in place when going into a medical facility, to the effect that:

"By entering the room of, accessing the medical information of, or providing any services, materials, medical supplies or other items to, the individual named below, hereafter "Patient", all billing individuals and entities agree to accept as payment in full whatever payment is provide by Patient's insurance. By accepting this agreement, all billing entities agree not to request, or accept, services on Patient's behalf from any entity not accepting this Agreement."

But, no, patients are essentially in a situation where anything and everything goes; potentially drugged, and/or in pain, and/or unconscious and generally not in a position to pay close attention and NO IDEA what will be charged or by whom, with patient wallets as the final settlement resource.

/sarc on
What could possibly go wrong?
/sarc off

quote:

Originally posted by henryaz:
 
I have had that happen with several surgeries, including knee replacement. The assistant was not Medicare certified. They (the assitant's company) tried billing me direct a couple of times. I called them up, and they are aware of the problem. They say they try billing because some supplements will pick up part of their bill (mine won't). They told me just to ignore the two bill attempts, and after that fails for them, they just write it off.
 
They do have assistants who are certified, and they use those whenever they can.

Keep all the documentation. The provider might sell this account to a collection agency and a few years from now you'll get collection calls.

Recommend you have emails (if possible with return receipt) or certified mail showing you protested the charges at the time.

This is one of the myriad ways in which the U.S. health "care" system is a total mess.

I had to deal with similar BS for simple labs because, while the hospital had correct, up-to-date insurance information, the various and sundry "independent contractors" did not, so we ended-up getting billed for stuff our insurance covered.

Luckily, in our case, they were easily-resolved with phone calls to update the independents.

It's a badly-broken system

Had a similar scenario happen to me with a cervical fusion surgery. I was able to negotiate the surgical assistant accepting my out of network reimbursement amount in lieu of full payment for the billed balance. In my case, that was in the 80k range. I was outraged that she submitted separate claims to my insurance, and for the amount that she did, considering that she is just a P.A.

I found out later that the surgical assistant is married to my surgeon. According to what I was told, she set up her her own business to bill for out of network provider reimbursements.

This out of network surprise billing has been around for a long time. 18 months after our son was born in 2001 I received a bill for some lab doing QC work on bloodwork taken shortly after he was born...I was just blown away that I was still getting bills 18 months after he was born. I was too naive at the time to tell them to pack sand and fight it.

What’s really maddening is our legislature continued refusal to take action to prevent surprise billing. When filling out paperwork, I always add “in network providers only” into the terms and conditions section. I print it neatly and add my initials. Although it’s not binding, I feel that it’s enough to provide some support of a refusal to pay. 99% of the time the adm never notices. Should I get a bill, I have a copy.

I have been having problems with my back for the past 5 months. Orthopedic surgeon wants to give me an injection in the back. Insurance will cover everything except the anesthesiologist. I asked what would that cost? They don't know. Then they want me to get a Covid test, stay home for a week to find out the results and then come in for the shot. I told them no. Shot may or may not work, you can't tell me what I have to pay and while you may know I don't have the virus, how do I know anyone in the surgery center that works on me does not have Covid.

Article I saw today about TEAMHEALTH, the ER staffing company I mentioned in my post:
Physician Staffing Firm Faces Suit Claiming Hospital, ER Billing Fraud

Amid ongoing scrutiny of its business practices, physician-staffing giant TeamHealth is now facing a class action suit accusing the company of fraudulent patient billing and racketeering.

The lawsuit, filed July 10 in US District Court for the Northern District of California, contends that TeamHealth vastly inflates the rates it charges patients and aggressively pursues debt collection if patients fail to pay the inflated prices. The complaint alleges TeamHealth is illegally engaging in the corporate practice of medicine and is avoiding state bans of this practice by operating a web of subsidiaries and purportedly independent organizations.

In a statement to Medscape Medical News, TeamHealth denied the claims and indicated that the company plans to aggressively fight the lawsuit.

"TeamHealth is confident that our billing practices and organizational structure are fully compliant with long established laws and precedents," TeamHealth said in an emailed statement. "TeamHealth maintains a long-standing practice against balance billing. We believe these claims are wholly without merit and we look forward to vigorously defending ourselves."

TeamHealth, based in Knoxville, Tennessee, is one of the largest providers of outsourced clinical staffing and administrative services for hospital-based and freestanding emergency departments in the country.

The company, which was acquired by private equity firm Blackstone Group LP in 2017, operates within 47 states and runs about 3300 acute and post-acute facilities. TeamHealth contracts with hospitals to staff and manage various departments, including emergency, critical care, radiology, and anesthesiology services. The company currently controls about 17% of the emergency medicine market in the United States, according to the legal challenge.

The class action suit claims that TeamHealth is practicing corporate medicine but is able to skirt state laws that prohibit the practice through a spectrum of so-called subsidiaries and "independent" contractors.

As director of the enterprise, TeamHealth controls the terms of its physicians' employment, all physician staffing decisions, and all the rates its physicians and practice groups charge patients, according to the suit. The complaint claims these rates are inflated far above what is reasonable and customary for the services provided.

The suit's lead plaintiff, Sia Fraser, claims she experienced just such inflated bills after an emergency department visit. Fraser was treated for emergency gallstone surgery by a physician in a TeamHealth-owned physician group in September 2019 at Tri-City Medical Center in Oceanside, California. TeamHealth billed Fraser $1082 for an hour of observation care during the visit, according to the suit. For the same hospital visit, TriCity Medical Center billed Fraser $63 per hour for observation care performed by hospital physicians.

Craig Briskin, an attorney for Fraser with the law firm Justice Catalyst Law, said his team intends to obtain substantial monetary relief for consumers in the case and aim to return fairness and common sense to medical billing.

"We saw so many people struggling with outrageously high medical bills and wanted to do something about it," Briskin told Medscape Medical News. "We also saw that TeamHealth's 'customers' never entered any agreement with them, let alone agreed on any price they would pay. In fact, most patients don't even know that they're being treated by TeamHealth employees until they get a bill. We believe that TeamHealth is defrauding consumers, and we filed this suit to hold the company accountable."

"A Contract Leveraging Tool"
The suit comes at the heels of growing skepticism about TeamHealth's practices. The company has come under fire in recent months for reportedly sending surprise bills to patients and slashing physicians' hours during the coronavirus health crisis, according to ProPublica. One analysis of the company's records by the news organization found that TeamHealth is substantially marking up medical bills to boost profits. Two TeamHealth affiliates in Texas, for instance, billed 7.7 times more than their actual costs for clinicians and support services, according to the June ProPublica report.

In a March 2019 letter to US senators in response to congressional inquiries into surprise billing, a spokesman for TeamHealth wrote that balance billing is "a contract leveraging tool" for the company.

"Balance billing yields immaterial revenue for TeamHeath and is not performed with the objective of enhancing revenue," TeamHealth President and CEO Leif Murphy wrote in the letter. "Rather, for TeamHeath and for emergency medicine providers as a whole, balance billing is our only available source of contract negotiating leverage."

In 2017, TeamHealth balance billed 0.16% of the patients who presented in its emergency departments. The average balance billed amount was $529, excluding patient cost sharing amounts, copayments, co-insurance, and deductibles, according to the letter.

"However, only 30% of the patients we balance billed actually remitted a full or partial payment for such amount," Murphy wrote. "In aggregate, TeamHealth receives just 0.08% (8 BPS) of our commercial fee-for-service collections from balance billed amounts."

LINK:https://www.medscape.com/viewarticle/934223?nlid=136550_5322&src=WNL_mdplsnews_200724_mscpedit_wir&uac=65325SY&spon=17&impID=2474894&faf=1