Surprise Bills Strike Again: What Your Clients Need To Know
Dr. Barbara Rutkowski & Joy McGee-Cory
June 2018

Health plans, employers and members are experiencing unexpected and very unpleasant surprises following certain complex surgical procedures, usually spine-related. The surprises are coming in the way of bills for intraoperative neurologic monitoring (IONM)—and can sometimes reach into six figures!

During IONM, a technician or physician observes neural structures, such as nerves, the spinal cord and parts of the brain, to identify issues that could damage the nervous system. By noting any potential for damage in real time, corrective action can be taken during surgery. 

Most often IONM is used during procedures by neurosurgeons; otolaryngologists; and vascular, orthopedic, or urology surgeons.

For any surgical procedure there are the usual and customary charges for things like surgical facility, surgeon, anesthesiologist, and even laboratory and radiology providers. But the problem arises when an out-of-network IONM technician provides a service during surgery, resulting in a higher-than-usual bill. 

Sometimes the patient has a Hobson’s Choice right before surgery when the vendor asks for a signature on a financial responsibility form. Because the patient feels pressured by the need for surgery or does not understand his or her responsibility for the high costs of out-of-network IONM services, he or she may sign the form and later regret the action.

When this happens, the health plan administrator has two options: Pay the usual and customary amount, or pay the entire claim, and then work to ensure this problem doesn’t happen in the future. In the former case, where the plan pays only the usual and customary, the out-of-network provider could balance bill the member, which would saddle members with debt in the best cases and could lead to bankruptcy in the worst cases. For health plans, the choice is a difficult one. 

In one case, the IONM technician was not a physician and the member’s bill for monitoring services was a non-negotiable $120,000. While the surgery was pre-certified, a surgeon can typically invite vendors into the operation that are out-of-network. Quite often no one knows this has happened until the bill appears. 

These exorbitant charges may be justified in instances of true medical emergencies, like rapidly progressing paralysis or loss of bladder control, but these cases are rare. 

However, scenarios like this can be prevented by monitoring contracts and claims, and predicting when an out-of-network IONM procedure could take place. 

Incidence of Spinal Surgery
The U.S. has more neurosurgeons per capita than nearly any other developed country; spinal surgery is twice as prevalent in the U.S. as it is in Europe or Canada and five times more common than in England.

As reimbursement rates have gone down, some spinal surgeons have turned to creative ways to improve their payments—like using assistants, especially out-of-network assistants, that can fly under the radar of an insurance company. 

Fighting Out-of-Network Bills
Some states have enacted laws to prevent members and health plans from being hit with surprise bills. In New York, doctors and hospitals must now disclose whether their services are covered by insurance in advance of a procedure. In addition, patients can’t be held responsible for charges beyond what they would have paid in-network. Insurers and hospitals must negotiate out-of-network payments or enter mediation. However, it appears that this coverage does not apply to self-insured plans. 

In 2017, Arizona joined a growing number of states in passing a law to help resolve the issue of “surprise bills” when a health plan member goes to an in-network hospital but also receives services from an out-of-network provider during the visit. The Arizona law provides a way for the member to dispute the bill and for the providers to get resolution and payment more quickly. 

However, members, health plans and employers aren’t protected from surprise bills in every state.

There have even been cases where a technician or physician bills for more monitoring time than was actually conducted. In one case, an IONM monitoring physician billed Medicare for six hours of monitoring services when, in reality, the surgical procedure lasted six hours but IONM only occurred for four. 

During this investigation, government officials also found that, contrary to policy, monitoring physicians would bill Medicare for multiple patients at the same time and bill separately for each patient—for example, a physician would monitor three patients for four hours each for a total of 12 hours, rather than only the time devoted to each individual patient. One potential solution is for health plans to require pre-certification nurses to record the actual monitoring time, and the number of patients that were monitored simultaneously, so that the IONM charges are correct.

IONM is valuable monitoring technology; however, it needs to be properly done by qualified professionals for complex cases where neural damage is a major risk. To rein in costs and ensure quality, it’s vital to be aware of this issue and work to identify excessive charges. 

By being proactive with these measures and having advanced healthcare analytics to help monitor member progress, conditions, treatments and claims, appropriate and reasonable claims will ensue.

Author's Bio
Dr. Barbara Rutkowski
EdD, MSN, CCM, is vice president, Clinical Operations at Advanced Plan for Health. She brings over twenty years of experience in operations, integrated medical management for health plans and self-insured employers, as well as care quality for hospitals and managed care organizations. Rutkowski can be reached at Advanced Plan for Health, 1500 Solana Blvd, Building 3, suite 3550, Westlake, TX 76262. Email: [email protected]

Joy McGee-Cory
is a senior vice president at Advanced Plan for Health. She advises health systems, managed care organizations, integrated delivery systems, and physician groups on managed care operations, provider compensation and contracting, regulatory compliance, and accreditation issues. McGee-Cory can be reached at Advanced Plan for Health, 1500 Solana Blvd, Building 3, suite 3550, Westlake, TX 76262. Email: [email protected]

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