Medicare and Medicaid have a long history of only paying small percentages of medical bills, so what do doctors do to make up for the lost fees? According to a shocking and thoroughly appalling New York Times expose, they use loopholes to essentially cheat patients and their insurance companies out of hundreds of thousands of dollars.

Such was the experience of Peter Drier, a 37-year-old New York man who went into a herniated disk surgery knowing that the procedure was not going to be cheap, but also knowing that his chief surgeon would accept a negotiated fee that was much less than the billed amount. In the New York Times article, Drier says that he thought he knew the risks of going through such an expensive surgery. He was wrong.

Shortly after surgery, Drier received a $117,000 medical bill from the office of Dr. Harrison T. Mu, a New York-based neurosurgeon. The amount on the bill was not even the most surprising part: brain and spinal surgeries routinely cost that much, if not more. No, more surprising was the fact that Drier had never met, spoken with, or even seen Dr. Mu. The bill, for all Drier knew, could have been someone’s fraudulent attempt to take advantage of him and his health insurance policy.

In reality, though, Mu actually had worked on Drier’s surgery, though not in an essential position. Mu was an assistant surgeon, helping Drier’s primary surgeon out with the procedure. Herniated disk surgeries and other similar procedures require a second set of trained hands, but the NY Times article says that Mu’s role could have been filled by a resident. Instead, though, the hospital called in Mu, an “out-of-network” physician who would be able to bill “20 to 40 times the usual local rates,” essentially for playing second fiddle.

Drier’s case is not unique. More and more these days, doctors are venturing to other hospitals for assistant roles that allow them to submit out-of-network billing and make a lot of money for a minimal amount of work. And because patients do not meet many of these healthcare professionals and are not even conscious during the surgeries and other procedures where their presences are deemed necessary, fighting back is often difficult.

A law is on the way for New York that will protect patients against unforeseen charges on their medical bills. However, given the way that laws, regulations, and government interference have caused healthcare costs to spiral out of control, the idea that the bill will make much of a difference is far-fetched at best. And since Drier’s insurance company ultimately paid Mu the full $117,000 bill – much more than was paid to the primary surgeon on the procedure – it is likely that doctors will continue to exploit the out-of-network and assistantship loopholes until some precedent is set to make them stop.