Izzy Benasso was playing a casual game of tennis with her father on a summer Saturday when she felt her knee pop. She had torn a meniscus, one of the friction-reducing pads in the knee, locking it in place at a 45-degree angle.
Although she suspected she had torn something, the 21-year-old senior at the University of Colorado Boulder had to endure an anxious weekend in July 2019 until she could get an MRI that Monday.
"It was kind of emotional for her," said 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 was scheduled for surgery on Thursday. Her father, who works in human resources, told her exactly what to ask the clinic regarding her insurance coverage.
Steve had double-checked that the hospital; the surgeon, Dr. James Genuario; and Genuario's clinic were all within her Cigna health plan's network.
"We were pretty conscious going into it," he said.
Isabel met with Genuario's physician assistant on Wednesday, and the following day underwent a successful meniscus repair operation.
"I had already gotten a ski pass at that point," Isabel said. "So that was depressing." But she was heartened to hear that with time and rehab she would get back to her active lifestyle.
Then a letter arrived that portended bills to come.
The patient: Izzy Benasso, a 21-year-old college student covered by her mother's Cigna health plan.
The total bill: $96,377 for the surgery was billed by the hospital, Sky Ridge Medical Center in Lone Tree, Colo., part of HealthONE, a division of the for-profit hospital chain HCA. It accepted a $3,216.60 payment from the insurance company, as well as $357.40 from the Benassos, as payment in full. The surgical assistant billed separately for $1,167.
Service provider: Eric Griffith, a surgical assistant who works as an independent contractor.
Medical service: Outpatient arthroscopic knee surgery to repair the meniscus.
What gives: The Benassos had stumbled into a growing trend in health care: third-party surgical assistants who aren't part of a hospital staff or a surgeon's practice. They tend to stay out-of-network with health plans, either accepting what a health plan will pay them or billing the patient directly. That, in turn, is leading to many surprise bills.
Even before any other medical bills showed up, Izzy received a notice from someone whose name she didn't recognize.
"I'm writing this letter as a courtesy to remind you of my presence during your surgery," the letter read.
It came from Eric Griffith, a Denver-based surgical assistant. He went on to write that he had submitted a claim to her health plan requesting payment for his services, but that it was too early to know whether the plan would cover his fee. It didn't talk dollars and cents.
Steve Benasso said he was perplexed by the letter's meaning, adding: "We had never read or heard of anything like that before."
Surgical assistants are not medical doctors, but serve as an extra set of hands for surgeons, allowing them to concentrate on the technical aspects of the surgery. Oftentimes other surgeons or physician assistants — or, in teaching hospitals, medical residents or surgical fellows — fill that role at no extra charge. But some doctors rely on certified surgical assistants, who generally have an undergraduate science degree, complete a 12- to 24-month training program and then pass a certification exam.
Surgeons generally decide when they need surgical assistants, although the Centers for Medicare & Medicaid Services maintains lists of procedures for which a surgical assistant can and cannot bill. Meniscus repair is on the list of allowed procedures.
A Sky Ridge spokesperson said that it is the responsibility of the surgeon to pre-authorize the use and payment of a surgical assistant during outpatient surgery, and that HealthOne hospitals do not hire surgical assistants. Neither the assistant nor the surgeon works directly for the hospital. UC School of Medicine, the surgeon's employer, declined requests for comment from Genuario.
Karen Ludwig, executive director of the Association of Surgical Assistants, estimates that 75% of certified surgical assistants are employed by hospitals, while the rest are independent contractors or work for surgical assistant groups.
"We're seeing more of the third parties," said Dr. Karan Chhabra, a surgeon and health policy researcher at the University of Michigan Medical School. "This is an emerging area of business."
And it can be lucrative: Some of the larger surgical assistant companies are backed by private equity investment. Private equity firms often target segments of the health care system where patients have little choice in who provides their care. Indeed, under anesthesia for surgery, patients are often unaware the assistants are in the operating room. The private equity business models include keeping such helpers out-of-network so they can bill patients for larger amounts than they could negotiate from insurance companies.
Surgical assistants counter that many insurance plans are unwilling to contract with them.
"They're not interested," said Luis Aragon, a Chicago-area surgical assistant and managing director of American Surgical Professionals, a private equity-backed group in Houston.
Chhabra and his colleagues at the University of Michigan recently found that 1 in 5 privately insured patients undergoing surgery by in-network doctors at in-network facilities still receive a surprise out-of-network bill. Of those, 37% are from surgical assistants — tied with anesthesiologists as the most frequent offenders. The researchers found 13% of arthroscopic meniscal repairs resulted in surprise bills, at an average of $1,591 per bill.
Colorado has surprise billing protections for consumers like the Benassos who have state-regulated health 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 consumers dispute surprise bills, has seen a lot of cases involving surgical assistants, said Adam Fox, director of strategic engagement.
Resolution: Initially, the Benassos ignored the missive. Izzy didn't recall meeting Griffith or being told a surgical assistant would be involved in her case.
But a month and a half later, when Steve logged on to check his daughter's explanation of benefits, he saw that Griffith had billed the plan for $1,167. Cigna had not paid any of it.
Realizing then that the assistant was likely out-of-network, Steve sent him a letter saying "we had no intention of paying."
Griffith declined to comment on the specifics of the Benasso case but said he sends letters to every patient so no one is surprised when he submits a claim.
"With all the different people talking to you in preop, and the stress of surgery, even if we do meet, they may forget who I was or that I was even there," he said. "So the intention of the letter is just to say, 'Hey, I was part of your surgery.' "
After KHN inquired, Cigna officials reviewed the case and Genuario's operative report, determined that the services of an assistant surgeon were appropriate for the procedure and approved Griffith's claim. Because Griffith was an out-of-network provider, Cigna applied his fee to Benasso's $2,000 outpatient deductible. The Benassos have not received a bill for that fee.
Griffith says insurers often require more information before determining whether to pay for a surgical assistant's services. If the plan pays anything, he accepts that as payment in full. If the plan pays nothing, Griffith usually bills the patient.
The takeaway: As hospitals across the country restart elective surgeries, patients should be aware of this common pitfall — and realize it's a fee they may have no recourse but to pay if their state doesn't have protections against surprise billing.
Chhabra said he's hearing more anecdotal reports about insurance plans simply not paying for surgical assistants, which leaves the patient stuck with the bill.
Chhabra said patients should ask their surgeons before surgery whether an assistant will be involved and whether 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 said. 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."
Bill of the Month is a crowdsourced investigation by Kaiser Health News and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!
MARY LOUISE KELLY, HOST:
Every month, NPR and Kaiser Health News take a close look at medical bills that you send us. And today, we're going to hear about a person called a surgical assistant. As the name suggests, this is someone trained to help a surgeon during certain operations. I want to bring in Elisabeth Rosenthal, who is not a surgical assistant. She is the editor-in-chief of Kaiser Health News.
Hey there, Elisabeth.
ELISABETH ROSENTHAL: Hi. How are you?
KELLY: I am well, thank you. So this is all newly relevant to be talking about because people are starting to have elective surgeries again after months of lockdown. I don't know that I had ever heard of a surgical assistant before. Is this something new?
ROSENTHAL: No, it's not really new. You know, there are some surgeries that take two sets of skilled hands, and so the primary surgeon would often call in an assistant. And sometimes that would be a resident or a kind of surgical assistant that was part of the hospital staff. What is new is that now people are getting billed and billed big for this service.
KELLY: Which is what brings us to bill of the month. Who are we going to meet today?
ROSENTHAL: Today, we're meeting Izzy Benasso and her father Steve. Izzy tore some of the cartilage in her knee and needed an elective knee surgery and ended up with a somewhat surprising bill.
KELLY: All right. And our guide to this is going to be Dan Weissmann, the host of "An Arm And A Leg" podcast, 'cause he talked to the Benassos. So let's listen.
DAN WEISSMANN, BYLINE: Izzy Benasso and her dad Steve were playing tennis last summer when Izzy had to make a big reach for the ball.
IZZY BENASSO: I pivoted really hard, and something didn't feel great. And before I knew it, I couldn't straighten out my legs.
WEISSMANN: She bent over and said, oh, no. Steve wasn't super concerned - at least at first.
STEVE BENASSO: Because she's been a competitive soccer player all her life, I just expected her to bounce back.
WEISSMANN: Izzy says it wasn't even the pain that had her shedding a tear. It was the thought she might have a serious knee injury.
I BENASSO: I've seen quite a few teammates tear ACLs and know what that recovery process was.
WEISSMANN: An MRI brought good news. Izzy's injury, a meniscus tear, would mean an easier recovery. She was in and out of surgery within a week. Izzy headed back to her senior year at college. Steve watched the mail for bills. Before the first one arrived, there was a letter from someone who said he was a surgical assistant.
S BENASSO: It was very cordial, and it basically was explaining that this was not a bill for services, that he had let Cigna, our insurance carrier, know that he was present during Izzy's surgery.
I BENASSO: Like they were just sneaking people in while I was unconscious, and then they could all write letters and say, hey, we were there, too.
WEISSMANN: A month later, a follow-up from the same guy with the same message. And to understand what Steve does next, there's a couple things worth knowing about him. First...
I BENASSO: Steve is the kind of person to check every receipt twice and argue over any discrepancies he finds.
WEISSMANN: Izzy says her family's gotten lots of free stuff as a result, like the supermarket manager who sent over a basket of food and some gift cards.
S BENASSO: That's, by far, not the best one. My wife and I received a free ski trip to Sun Valley once.
I BENASSO: Oh, yes. That one was good.
WEISSMANN: The other thing about Steve is his job. He's a human resource director, and he encourages people where he works to come to him with questions about their medical bills. Anything looks fishy, he goes to battle for them.
S BENASSO: I do it every month.
WEISSMANN: So this weird letter from a surgical assistant - Steve gets suspicious, writes the guy right back to say, I'm guessing you're telling me this so that I'm not surprised to get a bill from you. And I'm also guessing that you don't take our insurance, which is why you're trying to soften me up.
S BENASSO: And I want you to know that I have absolutely no intention of paying your bill. And if you feel that you're owed something for your services, I suggest you take it up with Izzy's surgeon and that you perhaps come to some sort of agreement on how to split the fee that he receives, or you can have the pleasure of arguing this with Cigna yourself. That's essentially what I said (laughter).
WEISSMANN: That letter is hilarious, and it seems to have worked. Steve says he hasn't heard from the guy since - no bill, no nothing.
For NPR News, I'm Dan Weissmann.
KELLY: All right. And I want to bring back in Elisabeth Rosenthal to explain what is going on here. How is it that somebody can try to charge for helping out during surgery?
ROSENTHAL: Well, this is kind of the latest twist on surprise out-of-network billing. And it results from what in the medical field is called unbundling. Stuff that used to be included in your hospital stay is suddenly charged item by item. So, you know, just for an example that we're more familiar with, you go to an emergency room, right? And suddenly, you get a big out-of-network bill from the ER doctor, or you get surgery, and you get an out-of-network bill from the anesthesiologist. This is taking that trend one step further because, hey, you know, she never even met this guy, and she's being billed for an extra set of hands in the OR. You take this to the next stage, and you think, wait; is the nurse who gives me a pill going to be charging a nursing pill delivery fee? I mean, it's really gotten somewhat out of hand.
KELLY: So what can we do about it, aside from finding a Steve Benasso who can write a fierce letter on our behalf? What can we do, Elisabeth Rosenthal?
ROSENTHAL: You can do a lot. If you're going in for an elective surgery, ask if there'll be a surgical assistant involved. And make sure they're in network, just like we've all been trained now to say, is the anesthesiologist in network? - because one of the things that surprised me about this is that surgical assistants have become one of the most common causes of surprise bills.
KELLY: So ask questions, ask questions, ask questions before you write any checks, it sounds like is the lesson here.
KELLY: All right. Elisabeth Rosenthal of Kaiser Health News, thank you so much.
ROSENTHAL: Thank you.
KELLY: And if you are listening and you have an outrageous or confusing or mysterious bill that you want us to take a look at, go to NPR's Shots blog and tell us about it. Transcript provided by NPR, Copyright NPR.