When Liv Cannon received a letter with a nearly $100,000 charge about a year after she had life-changing back surgery that was otherwise covered by her insurer, her fiancé thought it was a scam, Jon Hamilton reports for Kaiser Health News. It was not.

A life-changing surgery

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For almost all of her life, Cannon suffered from chronic pain and muscle weakness. She visited many doctors over the years, and none of them had an explanation for what was wrong.

"There was a lot of pain in my back, which I thought was, you know, just something everybody lived with," Cannon said.

But at her fiancé's urging, Cannon saw a specialist a few years ago, and the doctor discovered Cannon had a rare disorder that leads the spine to split in two. A scan also revealed a tumor in her spine.

So, in December 2017, Cannon, underwent spinal surgery.

Now, Cannon can do things like bending over in the garden and lifting the wheelbarrow—things she could never do before, she recalled.

"I think it was day 3 after my surgery I could feel the difference," Cannon said. "There was just a pain that wasn't there anymore."

A 'surprise' bill

Over the next year, Cannon recovered from the surgery and tracked bills coming in for the operation.

Then, one day, she received a piece of mail that said she'd been charged $94,031 for neuromonitoring services, which her surgeon had requested during the operation. The point of the service is help prevent a surgeon from unintentionally damaging the nerves permanently. It works by using electrical signals to detect when a surgeon is near a nerve, Hamilton reports.

It turns out, while her insurer picked up the more than $100,000 tab for her other medical bills—including those from the anesthesiologist, hospital, and surgeon—the neuromonitoring service was provided by Traxx Medical Holdings, an out-of-network provider for Cannon's plan.

Cannon's insurer, Blue Cross and Blue Shield of Texas, paid $815.69 of the neuromonitoring bill, and informed her she was responsible for the 93,991.58 balance.

The statement listed four charges from the day of the surgery, with each one described as "diagnostic medical exam." Cannon explained, "It was one of those things from the insurance company that says this is the amount we cover and this is the amount you might owe your provider," she said, referring to the explanation of benefits.

When the letter arrived, Cannon said she was "shocked." Her fiancé, Cole Chiumento, said, "I thought it was a scam."

How did this happen?

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Richard Vogel, president of the American Society of Neurophysiological Monitoring, said neuromonitoring is standard for operations like the one Cannon had. However, he said the price Traxx charged cannot be justified. "You're not going to meet anybody who believes that a hundred thousand dollars or more is reasonable for neuromonitoring."

According to Vogel, most neuromonitoring companies charge reasonable fees and are upfront about their financial arrangements. However, some submit exorbitant bills to insurers in the hopes the bill will get paid. And, Vogel added, "[S]ome neuromonitoring groups charge excessive fees in order to gain business by paying the money back to surgeons."

Hamilton reports that it's unclear whether Traxx has such arrangements.

Traxx did not respond to requests to comment, and neither did Cannon's surgeon, Hamilton reports.

Blue Cross and Blue Shield of Texas said it does not comment on specific cases but provided a general statement. "Unfortunately, non-contracted providers can expose our members to significantly greater out-of-pocket costs," the company stated. "These charges often have no connection to underlying market prices, costs or quality. If given the opportunity, we will try to negotiate with the provider to reduce the cost."

The ethical question

While Cannon had not expected the high charge, she recalled that she thinks she signed a paper authorizing the out-of-network neuromonitoring, Hamilton reports. "It was 4:30 in the morning and you're like, 'OK, let's get this over with.'"

Arthur Garson Jr., who directs the Health Policy Institute at the Texas Medical Center, said obtaining consent in the hospital may be legal but doing so is not reasonable. For instance, he pointed to a case when a patient is having a heart attack. "You got chest pain, you're sweating, sick as you can be, and they hand you a piece of paper and they say, 'Sign here.'"

To help patients like Cannon, Texas Gov. Greg Abbott (R) last week signed into law a bill (SB 1264) to protect patients from receiving surprise bills in stances in which the patient has little control over the provider that treats them. Similar legislation is under consideration in Congress.

"Asking the individual patient to make that decision even when they're not sick, I think, is difficult," Garson said, "and maybe we ought to think of some better way to do it."

However, the Texas law doesn't apply retroactively. That means Cannon is still on the hook for the neuromonitoring charge, Hamilton reports.

The situation is a major source of anxiety for Cannon and Chiumento, Hamilton reports. They've considered calling of their wedding, in the event a bill from Traxx or a collector comes. "I think about it every time I go to the mailbox," Cannon said  (Hamilton, Kaiser Health News/NPR, 6/17; O'Brien, HealthLeaders Media, 6/17). 

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