Upon recovering from surgery for two herniated disks, 37-year-old Peter Drier received a hefty bill for medical costs incurred. Of those costs, he found an unexpected charge of $116 862 from an “assistant surgeon”, Dr. Mu, whom he had no recollection of meeting.

Drier had fully researched his insurance coverage prior to surgery and was prepared to incur the costs he was notified of receiving: $56 000 in hospital fees from Lenox Hill Hospital in Manhattan, $4 300 for the anaesthesiologist, and $133 000 from the main surgeon, the orthopaedist whom he knew would accept only a small portion of the full cost. The additional $117 000 from the Queens-based neurosurgeon unknown to him was a shock that apparently is ongoing practice across the nation.

While it is common for surgeons and other healthcare providers to work in teams and help each other in providing patient care across operating rooms and hospital wards, it is becoming increasingly common for consults to be called in, without notice to the patient, for questionable circumstances, expecting the patient and/or insurance providers to pay large sums for such unnecessary services. Due to cuts across the board for reimbursement by insurers, the practice has become a form of increased revenue for the healthcare industry. Unfortunately for the patient and insurance companies, these surprise costs can become the largest portion of the bill, with most of the services being provided by out-of-network professionals who charge 20 to 40 times the local rates, and often collect that amount in full.

“The notion is you can make end runs around price controls by increasing the number of things you do and bill for,” said Dr. Darshak Sanghavi, a health policy expert at the Brookings Institution until recently. “This contributes to the nation’s $2.8 trillion in annual health costs.”

“I thought I understood the risks,” said Mr. Drier “But this was just so wrong — I had no choice and no negotiating power.” His concerns began even in the preoperative stage, when the hospital sent blood tests to an out-of-network lab, and ordered an unnecessary echocardiogram (ECG) for him. ECG testing for patients with no prior cardiac history is strongly discouraged by the American Society of Echocardiography – the ECG was later billed for $950.

Drier’s concerns further increased on the morning of his surgery, when he was approached by a private company called Intraoperative Monitoring Service L.L.C for an uninsured service that was requested as essential by his surgeon due to the intricacy and delicacy of the operative area around the nerves. “I demanded to know the price, and when he said he didn’t know, I made him call,” recalled Drier. Despite being on the operating table being prepped for surgery, he managed to negotiate the quoted $500 plus an hourly rate down to $300.

Most recently, such surprise charges have become the top complaint to insurance company regulators in New York State. Commissioners have tried, in vain, to limit liability faced by patient’s – overcoming fierce healthcare industry lobbying has become their largest obstacle. In Drier’s case, the insurance company agreed that it was unreasonable to have him pay out-of-pocket, and simply wrote out a cheque in full to Drier to pass on to Dr. Mu.

Dr. Tindel was getting paid $6 200 of the full medical resulting from prior negotiation between Drier and his insurance company, while Dr. Mu would get the full sum of almost $117 000. Shocked and appalled, Drier made an attempt to have the lump sum divided reasonably between both surgeons.

According to an e-mail by Drier, his idea was to settle on “a reasonable fee for both the surgeon and assistant and return the rest of the check to the insurance company/employees” of his company. Unfortunately for Drier, he received a threatening notice from Dr. Mu’s legal counsel regarding failure to forward payment, and begrudgingly sent along the cheque.

To prevent such surprises from occurring, some insurance companies have taken legal action in the form of lawsuits and injunctions in protection of their clients. Other insurers have refused to do business with in-network professionals who deliberately and repeatedly request consults from out-of-network specialists without informed consent from the patient.

Legislation in New York State will target such practices by requiring advance disclosure from healthcare providers and the hospitals themselves on whether or not the services implemented on a patient are covered by their insurance policy. It further states that patents are not to be held responsible for serendipitous out-of-network charges beyond the scope of what would have been pain in-network. Such legislation attempts to model services in other countries with private healthcare systems, where informed consent prior to hospitalization, of such out-of-pocket costs is seen as the patient’s right.