Several of our Health Plan clients and their members have experienced unexpected and very unpleasant surprises following certain complex surgical procedures – usually spine-related. So we wanted to get a cautionary word out a bit more broadly on this topic to our clients and others who may be facing similar situations.
The surprises are coming in the way of bills for intraoperative neurologic monitoring (IONM).
For background from Wikipedia: IONM utilizes electrophysiological methods such as electroencephalography (EEG), electromyography (EMG) and evoked potentials to monitor certain neural structures such as nerves, spinal cord and parts of the brain during surgery. Most neuromonitoring is utilized by spine surgeons, but neurosurgeons, vascular, orthopedic, otolaryngologists and urology surgeons have all utilized neuromonitoring as well. A trained physician or neurophysiology technician uses this technology in real time to alert the surgeon and anesthesiologist of changes that could portend damage to the nervous system during an invasive procedure, so that immediate corrective intervention is possible.
With these surgical procedures, there are the usual bills (surgical facility, surgeon, anesthesiologist, and even laboratory and radiology providers) and then the member receives an out- of-network bill for intraoperative neurologic monitoring (IONM) at a rate that’s significantly higher than usual local rates.
In one case, the billing technician was not a physician, and the member’s bill for monitoring services was an unreasonable, non-negotiable $120,000.
The Plan administrator had to make the difficult decision of paying the usual and customary amount or paying the entire claim, and then working to ensure that this problem would be fixed for future cases.
The choice was difficult because out-of-network vendors can balance bill the member, which could put many end-consumers at risk of bankruptcy.
At Advanced Plan for Health (APH), we allow top procedures such as this to be monitored in detail, so that adequate information is available to educate providers, encourage network contracts with vendors and work with hospital clients and their surgical teams to get IONM vendors into the network and under contract.
Elisabeth Rosenthal with The New York Times reported on an actual case where a patient, Peter Drier, required back surgery to relieve pain from his herniated disc and then experienced an unexpected financial shock first hand. His surgeon hired an out-of-network neurological assistant who billed him for an additional $117,000, even though the surgeon had agreed to accept a reasonable, negotiated fee.
The real issue is that while the surgery is pre-certified, the surgeon can invite vendors into the operation that are out-of-network. Quite often, no one knows this has happened until the bill appears.
Health Plans have limited ability to fight back other than to pay the bill, leave the member vulnerable for balance billing, or file a lawsuit for recoupment.
Sometimes the patient has a Hobbs 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 extreme potential costs of out-of-network IONM services, he or she may sign the form and later regret the action.
Before your Plan gets stuck on the horns of this dilemma, let’s review the technology, the efficacy and appropriate use of this technology, the swirling controversies and how to prevent inordinate claims from impacting your Health Plan.
Incidence of Spinal Surgery
You may be surprised to hear that according to The New York Times, the USA has more neurosurgeons per capita than nearly any other developed country, and that spinal surgery is twice as prevalent in the USA as it is in Europe or Canada and five times that of England.
Further, as reimbursement rates have gone down, some spinal surgeons have turned to creative ways to improve their payments; like using an assistant, especially one that is out of network and flies under the radar of the insurance company. 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.
Benefits of IONM are Controversial
The Oschner Clinic Foundation, Department of Neurosurgery did a retrospective database review of 112 patients who had minimally invasive 1 or 2 level transforaminal lumbar interbody spinal fusions. The conclusion published in the Ochsner Journal 14:57-61 in 2014 was that the average length of stay and reoperation were not statistically significant between the monitored and unmonitored groups, but the time in surgery and the cost was significantly higher for the monitored group.
Some insurance companies are setting criteria to limit abuse of IONM by reserving this technology for specified high risk, complex surgeries and outlining criteria and determinants of medical necessity in their clinical guidelines.
New York led the way toward remedying the problem of “surprise bills” with legislation effective in 2015 that requires doctors and hospital to disclose, in advance, whether their services are covered by insurance according to the New York Department of Financial Services.
The law further says that patients cannot be held responsible for charges beyond what they would have paid in-network. Insurers and hospitals have to negotiate out of network payments or enter mediation. However, it appears that this coverage does not apply to self-insured plans.
This legislation is only a start to providing relief from the widespread practice of balance billing for out-of-network services.
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 a network hospital but also receives services from an out-of-network provider during the visit. The Arizona law provides a mechanism for the member to dispute the bill and for the providers to get resolution and payment more quickly.
Lessons Learned from Medicare
According to the FBI, the United States Attorney’s Office filed suit in federal district court against Jeffrey B. Owen, CEO and Surgical Monitoring Systems (SMS) dba Sentient Medical Systems under the False Claims Act and the government prevailed in getting Owen and SMS’ agreement to pay a $2.7 million settlement in November, 2010.
The takeaway from this case is that the government was falsely billed for monitoring services for 6 hours, when monitoring was only done for 4 hours. Further, when the physician monitored 3 patients simultaneously, he had to divide the 4 hours among the 3 patients. Instead he had billed four hours for each of the 3 patients, or 12 total hours. Perhaps, Health Plans can require pre-cert nurses to record the actual monitoring time, and the number of patients that were monitored simultaneously, so that the IONM charges are correct.
The bottom line is that IONM is valuable monitoring technology designed to alert the surgical team during surgeries that could result in severe neurological complications for problems that can be corrected in real time. However, there have been reported incidences of inappropriate use and possible abuse. IONM 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, Health Plans and Networks need to work proactively with their clients to identify the excessive charges that can be incurred when the neuro monitoring is improperly billed or done by an out-of-network vendor and / or physician(s).
Advanced Plan for Health helps our clients to identify the surgeries where IONM is likely to be utilized, then find the costs of IONM for the cases that slip through the system – especially with out-of-network providers. APH then assists Plans by identifying providers that need to be contracted, and / or establish reasonable reimbursement for the services rendered.
Hospitals and surgical centers need to require all providers to identify what services they will provide and the costs well ahead of the surgery, not when the person is ready to be wheeled into the operating room.
Utilization Review Teams need to ask questions about any external vendors that the surgeon plans to use, expected billed charges, the availability of in-network providers, the time monitoring will be needed, if the patient will be monitored simultaneously with others, and the exact technology required by the particular surgery.
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.
Contact us if you’d like to learn more about how our Poindexter analytics can deliver the visibility you need to identify IONM risk or other risk areas within your population.