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 billing 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 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, who until recently was a health policy expert at the Brookings Institution. 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 Donelon, the Republican insurance commissioner of Louisiana. "But when you try to address it as a policymaker, you run into a hornet's nest of financial interests."
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, 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 New York City neurosurgeon whom Drier had never met.
"I thought I understood the risks," Drier, who lives in New York City, said later. "But this was just so wrong -- I had no choice and no negotiating power."
In Drier's case, the primary surgeon, Dr. Nathaniel Tindel, had said he would accept a negotiated fee determined through Drier's insurance company, which ended up being about $6,200. (Drier had to pay $3,000 of that to meet his deductible.) But the assistant, Dr. Harrison Mu, was out of network and sent the $117,000 bill. Insurance experts say surgeons and assistants sometimes share proceeds from operations, but Tindel's office said he and Mu do not. 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.
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 spokesman 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.
So sometimes insurers just pay -- to protect their customers, they say -- which encourages the practice. When 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 Mu for $116,862, the full amount.
When 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 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.
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.
One insurer, Aetna, is in court with Mu's private-practice group, NeuroAxis Neurosurgical Associates of Kew Gardens, Queens. NeuroAxis sued over low insurance payments, and Aetna says the practice's fees 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.
For months, Drier stewed over what to do with the $117,000 check Anthem Blue Cross had sent him to pass on to Mu, refusing to sign over a payment he considered "outrageous and immoral." He worried that such payments could drive up premiums at his employer.
Drier tried to negotiate with the surgeons to divvy up the $117,000 payment in a way he believed was more fair; he liked Tindel and felt he was being underpaid. 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 Mu's lawyer noting that he had failed to forward the $117,000 check. So he sent it along, with regret.
SundayMonday on 09/21/2014