Izzy Benasso was taking part in an informal recreation of tennis together with her father on a summer season Saturday when she felt her knee pop. She had torn a meniscus, one of many friction-reducing pads within the knee, locking it in place at a 45-degree angle.
Although she suspected she had torn one thing, the 21-year-old senior on the University of Colorado in Boulder needed to endure an anxious weekend in July 2019 till she might get an MRI that Monday.
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“It was kind of emotional for her,” stated 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 or he was scheduled for surgical procedure on Thursday. Her father, who works in human sources, informed her precisely what to ask the clinic concerning her insurance coverage protection.
Steve had double-checked that the hospital; the surgeon, Dr. James Genuario; and Genuario’s clinic had been in her Cigna well being plan’s community.
“We were pretty conscious going into it,” he stated.
Isabel met with Genuario’s doctor assistant on Wednesday, and the next day underwent a profitable meniscus restore operation.
“I had already gotten a ski pass at that point,” she stated. “So that was depressing.” But she was heartened to listen to that with time and rehab she would get again to her energetic way of life.
Then the letter arrived, portending of payments to return.
The Patient: Izzy Benasso, a 21-year-old school scholar coated by her mom’s Cigna well being plan.
The Total Bill: $96,377 for the surgical procedure was billed by the hospital, Sky Ridge Medical Center in Lone Tree, Colorado, a part of HealthONE, a division of the for-profit hospital chain HCA. It accepted a $three,216.60 fee from the insurance coverage firm, in addition to $357.40 from the Benassos, as fee in full. The surgical assistant billed individually for $1,167.
Service Provider: Eric Griffith, a surgical assistant who works as an impartial contractor.
Medical Service: Outpatient arthroscopic meniscus restore surgical procedure.
What Gives: The Benassos had stumbled right into a rising development in well being care: third-party surgical assistants who aren’t a part of a hospital workers or a surgeon’s follow. They have a tendency to remain out-of-network with well being plans, both accepting what a well being plan pays them or billing the affected person immediately. That, in flip, is resulting in many shock payments.
Even earlier than some other medical payments confirmed up, Izzy acquired a discover from somebody whose title she didn’t acknowledge.
“I’m writing this letter as a courtesy to remind you of my presence during your surgery,” the letter learn.
It got here from Eric Griffith, a Denver-based surgical assistant. He went on to write down that he had submitted a declare to her well being plan requesting fee for his companies, however that it was too early to know whether or not the plan would cowl his charge. It didn’t discuss dollars and cents.
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Steve Benasso stated he was perplexed by the letter’s that means, including: “We had never read or heard of anything like that before.”
Surgical assistants function an additional set of palms for surgeons, permitting them to focus on the technical points of the surgical procedure. Oftentimes different surgeons or doctor assistants — or, in instructing hospitals, medical residents or surgical fellows — fill that function at no additional cost. But some medical doctors depend on licensed surgical assistants, who typically have an undergraduate science diploma, full a 12- to 24-month coaching program, after which move a certification examination.
Surgeons typically determine after they want surgical assistants, though the Centers for Medicare & Medicaid Services maintains lists of procedures for which a surgical assistant can and can’t invoice. Meniscus restore is on the checklist of allowed procedures.
A Sky Ridge spokesperson stated that it’s the accountability of the surgeon to preauthorize the use and fee of a surgical assistant throughout outpatient surgical procedure, and that HealthOne hospitals don’t rent surgical assistants. Neither the assistant nor the surgeon works immediately for the hospital. UC School of Medicine, the surgeon’s employer, declined requests for remark from Genuario.
Karen Ludwig, govt director of the Association of Surgical Assistants, estimates that 75% of licensed surgical assistants are employed by hospitals, whereas the remainder are impartial contractors or work for surgical assistant teams.
“We’re seeing more of the third parties,” stated Dr. Karan Chhabra, a surgeon and well being coverage researcher on the University of Michigan Medical School. “This is an emerging area of business.”
And it may be profitable: Some of the bigger surgical assistant firms are backed by personal fairness funding. Private fairness corporations usually goal segments of the well being care system the place sufferers have little selection in who gives their care. Indeed, below anesthesia for surgical procedure, sufferers are sometimes unaware the assistants are within the working room. The personal fairness enterprise fashions embrace retaining such helpers out-of-network to allow them to invoice sufferers for bigger quantities than they may negotiate from insurance coverage firms.
Surgical assistants counter that many insurance coverage are unwilling to contract with them.
“They’re not interested,” stated Luis Aragon, a Chicago-area surgical assistant and managing director of American Surgical Professionals, a non-public equity-backed group in Houston.
Chhabra and his colleagues on the University of Michigan just lately found that 1 in 5 privately insured patients present process surgical procedure by in-network medical doctors at in-network services nonetheless obtain a shock out-of-network invoice. Of these, 37% are from surgical assistants, tied with anesthesiologists as essentially the most frequent offenders. The researchers discovered 13% of arthroscopic meniscal repairs resulted in shock payments, at a median of $1,591 per invoice.
Colorado has shock billing protections for customers just like the Benassos who’ve state-regulated well being 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 customers dispute shock payments, has seen a variety of circumstances involving surgical assistants, stated Adam Fox, director of strategic engagement.
Resolution: Initially, the Benassos ignored the missive. Izzy didn’t recall assembly Griffith or being informed a surgical assistant could be concerned in her case.
But a month and a half later, when Steve logged on to test his daughter’s clarification of advantages, he noticed that Griffith had billed the plan for $1,167. Cigna had not paid any of it.
Realizing then that the assistant was probably out-of-network, Steve despatched him a letter saying “we had no intention of paying.”
Griffith declined to touch upon the specifics of the Benasso case however stated he sends letters to each affected person so nobody is shocked when he submits a declare.
“With all the different people talking to you in pre-op, and the stress of surgery, even if we do meet, they may forget who I was or that I was even there,” he stated. “So the intention of the letter is just to say, ‘Hey, I was part of your surgery.’”
After KHN inquired, Cigna officers reviewed the case and Genuario’s operative report, decided that the companies of an assistant surgeon had been applicable for the process and accepted Griffith’s declare. Because Griffith was an out-of-network supplier, Cigna utilized his charge to Benasso’s $2,000 outpatient deductible. The Benassos haven’t acquired a invoice for that charge.
Griffith says insurers usually require extra data earlier than figuring out whether or not to pay for a surgical assistant’s companies. If the plan pays something, he accepts that as fee in full. If the plan pays nothing, Griffith often payments the affected person.
The Takeaway: As hospitals throughout the nation restart elective surgical procedures, sufferers ought to pay attention to this frequent pitfall.
Chhabra stated he’s listening to extra anecdotal experiences about insurance coverage merely not paying for surgical assistants, which leaves the affected person caught with the invoice.
Chhabra stated sufferers ought to ask their surgeons earlier than surgical procedure whether or not an assistant will likely be concerned and whether or not 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 stated. 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.”
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Markian Hawryluk: MarkianH@kff.org”>MarkianH@kff.org, @MarkianHawryluk