Viewpoint Addresses Managed Care Challenge for Surgeons: Avoiding Out-of-Network Bills for Consults

Two physicians writing for JAMA Surgery yesterday addressed a problem surgeons face in the era of managed care: how to make sure that an intraoperative consult doesn’t result in a large, unexpected bill for the patient.

Christina A. Minami, MD, and Karl Y, Billimoria, MD, MS, both of Northwestern University’s Feinberg School of Medicine, outlined the conundrum in their viewpoint, “Separating the Need for Intraoperative Consultation From the Fear of Out-of-Network Billing: The Myth of Drive-by Doctoring.” In their essay, the physicians take note of public reaction to a consultation case involving neurosurgery, which resulted in a patient receiving a $117,000 bill for care from an out-of-network provider.

“The cases in the media seem more striking as an indicator of payer system issues and poor communication in health care than of the inappropriate use of intraoperative consultation,” they write.

In other words, while patients may be justifiably upset to receive a bill from a physician they’ve never met, it usually doesn’t mean that person’s help wasn’t needed. It can mean, however, that the chief surgeon or the hospital failed to take steps to keep the bill from arriving—or that the surgeon didn’t tell the patient about the consultation. “When out-of-network billing does occur, even if the surgical outcome substantially contributed to a good surgical outcome, it can leave the patients feeling betrayed and frustrated by their lack of agency,” the authors write.

An intraoperative consult can happen for many reasons, both planned and unplanned. Minami and Billimoria cite the example of an orthopedic surgeon who seeks the assistance of a vascular surgeon while operating on the spine. For that operation, the surgeon should get an intraoperative consult cleared by the patient’s insurer in advance; if there is to be a deductible for the patient, there should be advance warning.

More problematic are the emergent cases, in which something unexpected happens—such as the discovery of a tumor—that demands immediate attention. The authors suggest that coverage allowances that payers make for emergencies generally should be extended to intraoperative consultations in such cases.

The authors note that the move toward bundled payments by the Centers for Medicare and Medicaid Services (CMS) takes the fear out of the equation, at least for patients. It’s up to the payer, or perhaps the large provider, to divide up who gets what when multiple hands take part in surgery. “It should fall on the hospital to ensure that the care bundle does not allow for out-of-network physicians to bill separately for serves rendered,” they wrote, noting that in these cases, sharing the workload might mean smaller payments for everyone.

The best answer, the authors write, is a commitment to transparency and disclosure of healthcare reforms. “Certain complications are unavoidable in surgery,” they write. “This is not one of them.”

Reference

Minami CA, Billimoria KY. Separating the need for intraoperative consultation from the fear of out-of-network billing: the myth of drive-by doctoring [published online March 18, 2015]. JAMA Surgery. doi: 10.1001/amasurg.2014.3521.