Julia Robinson for Kaiser Health News
The spinal surgery allowed Liv Cannon to plant his first vegetable garden.
"It's a lot of bending over and lifting the wheelbarrow and laying pickets in the ground," she says as she examines tomatillos, cherry tomatoes and eggplants growing in raised beds behind her house. Austin, Texas. "And nothing I could have done before."
In the first 24 years of his life, Cannon's activities were limited by chronic pain and muscle weakness.
"There was a lot of pain in my legs, which I can now recognize as a nerve pain," she says. "There was a lot of pain in my back, what I thought I was, you know, just something everyone had lived through."
Cannon has seen many doctors over the years. But they could not explain what was happening. She had pretty much given up trying to find a solution to her pain until her fiance, Cole Chiumento, pushed her to try again.
Julia Robinson for Kaiser Health News
"Things have never improved, they have never improved," says Chiumento. "That did not seem right to me."
So Cannon went to a specialist who ordered a scan of his spine. A few days later, his phone rang.
"We found something on your MRI," said one voice.
The images showed that Cannon was born with diastematomyelia, a rare disease related to spina bifida. It causes division of the spinal cord in two.
In the case of Cannon, the disorder also resulted in a tumor that trapped the spinal cord, causing it to stretch as it grew.
In December 2017, a neurosurgeon opened her spine and worked for several hours, releasing the cord.
"I think it was the third day after my operation and I could feel the difference," Cannon said. "There was just a pain that was no longer there."
As she was recovering, Cannon saw many medical bills go through. They were all covered by his insurance plan. Almost a year passed after the operation.
Then a new bill arrived.
Patient: Liv Cannon, 26, of Austin, Texas. At the time of her operation, she was a graduate student insured with Blue Cross and Blue Shield of Texas through her work at the University of Texas.
Total invoice: $ 94,031 for neuromonitoring services. The invoice was submitted to Blue Cross and Blue Shield, Texas, who covered $ 815.69 of the amount and informed her that she was responsible for the balance. The insurer was covering all other Cannon medical expenses, which exceeded $ 100,000, including those of the hospital, the surgeon and the anesthetist.
Service provider: Traxx Medical Holdings LLC, an Austin company that provides neuromonitoring during spinal surgery. Neuromonitoring uses electrical signals to detect when the surgeon damages the nerves.
Medical service: Cannon was born with a rare spinal condition that had caused her chronic pain and muscle weakness since childhood. In December 2017, she had a successful spinal surgery to correct the problem. His surgeon requested neuro-monitoring during the operation.
Which give: Neuromonitoring was logical for the type of surgery that Cannon was undergoing. The bill does not have. Cannon should have been warned well before the operation that the neuromonitoring company would be an off-grid provider whose fees might not be covered by its insurer.
At first, she was confused by the billing information that Blue Cross had sent her. "It's one of the things the insurance company says is the amount we cover and you may owe to your provider," she says.
The statement mentioned four separate charges as of the day of his operation. Each has been described as a "diagnostic medical examination". Together, they reached $ 94,031.
Blue Cross said the amount covered was $ 815.69 – less a deductible of $ 750 and $ 26.27 for co-insurance – and informed Cannon that it might have to pay the balance – 93,991, USD 58.
"I was shocked," she says. Chiumento was outraged.
"As soon as I saw that, I thought it was a scam," he says.
The bill came from an Austin company called Traxx Medical Holdings LLC. Traxx has not responded to e-mails, phone calls and a fax requesting comments on the charges.
The company's website states that Traxx provides a service called intraoperative neurophysiological monitoring, which assesses the function of nerves during surgery. The goal is to help a surgeon avoid causing permanent damage to the nervous system.
A debate is underway to find out if neuromonitoring is necessary for all spinal surgeries. But this is a complex operation like Cannon's, says Richard Vogel, president of the American Society of Neurophysiological Monitoring.
On the other hand, a $ 94,000 fee for the service can not be justified, says Vogel.
"You will not meet anyone who thinks that one hundred thousand or more dollars is reasonable for neuromonitoring," says Vogel.
Most neuromonitoring companies charge a reasonable fee for a valuable service and are frank about their property and financial arrangements, he says. But some companies are greedy and submit huge bills to an insurance company, hoping not to be challenged, he adds.
Even worse, "some neuromonitoring groups charge excessive fees in order to save time by reimbursing surgeons," said Vogel.
Last year, the Vogel Group issued a position statement condemning these "kickback agreements" and other unethical business practices.
It is unclear whether Traxx, the company that provided neuromonitoring to Cannon, has made financial arrangements with surgeons. The Cannon surgeon did not respond to requests for comment.
The amount of the fee for Cannon's neuromonitoring was only part of the problem. The other part was that Traxx – unlike his hospital, his surgeon, and his anesthetist – had no contract with Blue Cross and Blue Shield of Texas.
As an off-grid provider, the company could set its own fees and try to collect from Cannon any money it did not receive from its insurer.
Blue Cross and Blue Shield of Texas said they did not comment on issues that affect individual members. But the insurer made a general statement by email about the problem:
"Unfortunately, non-outsourced suppliers can expose our members to significantly higher additional costs, which are often unrelated to prices, costs or the quality of the underlying market. On occasion, we will try to negotiate with the supplier to reduce costs. "
One of the things that weighs on Cannon is that she is pretty sure that just before the surgery she signed a document that allowed off-net neuromonitoring.
"It was 4:30 in the morning and you're saying" OK, let's finish it, " she recalls.
Getting consent at the hospital can be legal, but it's not reasonable, says Dr. Arthur Garson Jr., director of the Health Policy Institute of Texas Medical Center in Houston.
For example, a patient might have a heart attack, Garson says. "You have chest pain, you sweat, you are sick as you can be, and they give you a piece of paper and they say:" Sign here. "
The Texas legislature passed a bill in May to protect patients from the exorbitant bills that this practice can cause. And Congress is considering similar legislation.
These are small steps in the right direction, says Garson.
"Asking each patient to make that decision even when they are not sick, is difficult," he says, "and we should perhaps think of a better way to do it."
Texan legislation is expected to come into force later this year, but it only applies to bills after it has been passed. So, this figure of $ 94,000 is never far from Cannon's mind, even though she and Chiumento plan their wedding.
"Every time I go out and get the mail, I wonder," Is it the day it's going to come and we're going to have to deal with it? " " " she says.
The delivery: Neuromonitoring during complex surgery involving the spine can help prevent accidental damage. But surveillance may be useless for low-risk back operations, such as spinal fusion.
It is odd that neuromonitoring be billed as a separate service, rather than a part of the spinal surgery. Cardiac monitoring is not billed separately during a bypass, for example.
When considering spinal surgery, ask your doctor if neuromonitoring will be part of the procedure. If yes, will it be billed separately? Try to find the supplier's name and get a preliminary estimate of the cost.
Check with your insurer to find out if the neuromonitoring provider is in your network and to make sure the estimated costs will be covered.