Written by Ryan Rosenhahn
I have been in the IntraOperative Neuromonitoring, IONM, industry for over 10 years, attending society meetings with ACNS, ASET, ASNM, NASS, AES, and many more. I have enjoyed travel to over 20 states, meeting with hospitals, surgeons, and IONM staff. I have much gratitude to embark on this career path, meeting so many great people along the way and contributing to improving patient outcomes. During this time, we have experienced an influx of private equity groups buying up companies, the introduction of G0453 (“G Code”) by Medicare, and 32 channels! Considering these major changes in the industry, the most striking change I have been exposed to has been the excessive amounts billed out-of-network. I’ve seen gross abuse of this model ranging from $70,000 to over $400,000 for a single procedure.
As an IONM professional, why should you care? You probably make a great salary, have a pretty good schedule, and you’re not hurting anyone because your company doesn’t balance bill the patients, right? There are very few, if any, abuses in life that do not come with consequences. Excessive out-of-network billing should be a hot topic, yet it is hardly discussed.
Follow the Money
Let’s start by stating the obvious… that if your company is billing six figures ($100,000 plus) for a single IONM procedure, it should raise some questions. I don’t think I have ever met a surgeon who would be okay with an IONM company billing more than the surgeon him/herself. So, your first question should be, “Why is the surgeon okay with this arrangement? What is the motivation for having your company in the OR? Is it really that your IONM skills are so superior to any other provider or is there something else going on?”
Next, I would ask, ”Is the practice of excessive billing creating sustainability in our field? What is the end result when insurance providers start catching on and stop reimbursing for IONM?” If you think this won’t happen, think again. For over 18 months, we have been in negotiations with two national insurance providers who are considering not reimbursing for IONM. Aetna and Cigna just announced no reimbursement for procedures below L1-L2. There are more on the way. How much literature is out there that really supports the intervention IONM provides? How much of that literature looks at multimodality monitoring? Are the decision makers at your company making the decision to promote, progress, and sustain the field of IONM?
But this doesn’t really affect the patient because we don’t bill the patient for anything not paid by insurance, right? Wrong! Your patients can be negatively affected in a number of ways. This can include their credit, insurance premiums increasing, being dropped from their insurance provider, and in some cases, bankruptcy. Additionally, your patients have a contract (with their insurance company) and by not being charged for anything this could be a breach of their contract.
Do you know what codes are being billed? The most common CPT code billed for the Technical time (in OR) is 95940. While I strongly believe there should be a time-based code to reimburse for the Technical Component (similar to when we had 95920), I can assure you that 95940 is not that code. 95940 is a Professional code that should only be billed when the Interpreting Reader is in the OR. Look up the AAN Principles of Coding for IONM and Testing as well as AMA National CPT Coding. If this isn’t enough (to convince you that 95940 is a Professional code), I encourage you to ask the people who wrote the code, as UCLA Neurologist Dr. Marc Nuwer will unequivocally tell you this is a Professional code only. Furthermore, you should really check into if this is being billed under your NPI number.
So, who is really benefitting from this practice? Is the owner of your company just out to make more money? Are they trying to “build up the books” with the goal of selling to another company or private equity investors? What is their true level of commitment to the betterment of the IONM field? Will your surgeons keep your company around based solely on clinical performance? What happens when insurance providers stop making a percent payment of billable charges? Your company will have to drastically change their operations and what you may currently experience as “normal” will change. I am certain major changes are coming and COVID-19 is only going to accelerate these changes.
I could name over 15 companies billing excessive charges for IONM and misusing the 95940 code, but what good will it do for me to name them here. It is time you start asking questions of your company and perhaps take action.
I strongly believe in IONM and I want to see this field continue in a sustainable, ethical manner. I also believe we all have a responsibility to better the healthcare system. While I believe the insurance companies are responsible for so much that is wrong with our healthcare system today, I also believe that two wrongs don’t make a right. I am privileged to play a role in medicine and when you commit to a career in medicine you commit to do no harm.