Spinal surgery made it possible for Liv Cannon to plant her first vegetable garden.

"It's a lot of bending over and lifting the wheelbarrow and putting stakes in the ground," the 26-year-old says as she surveys the tomatillos, cherry tomatoes and eggplants growing in raised beds behind her house in Austin, Texas. "And none of that I could ever do before."

For the first 24 years of her 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 nerve pain," she says. "There was a lot of pain in my back, which I thought was, you know, just something everybody lived with."

Cannon saw lots of doctors over the years. But they couldn't explain what was going on. She'd pretty much given up on finding an answer for her pain until her fiancé, Cole Chiumento, pushed her to try one more time.

"It never improved. It never got better," Chiumento says. "That just didn't sound right to me."

So Cannon went to a specialist who ordered a scan of her spine. A few days later, her phone rang.

"We found something on your MRI," a voice said.

The images showed that Cannon had been born with diastematomyelia, a rare disorder related to spina bifida. It causes the spinal cord to split in two.

In Cannon's case, the disorder also led to a tumor that trapped her spinal cord, causing it to stretch as she grew.

In December 2017, a neurosurgeon opened up her spinal column and operated for several hours, freeing the cord.

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

As she recovered, Cannon saw lots of huge medical bills go by. They were all covered by her insurance plan. Almost a year went by after the operation.

Then a new bill came.

Patient: Liv Cannon, 26, of Austin, Texas. At the time of her surgery, she was a graduate student insured with Blue Cross and Blue Shield of Texas through her job at the University of Texas.

Total bill: $94,031 for neuromonitoring services. The bill was submitted to Blue Cross and Blue Shield of Texas, which covered $815.69 of the amount and informed her she was responsible for the balance. The insurer covered all of Cannon's other medical bills, which came to more than $100,000, including those from the hospital, surgeon and anesthesiologist.

Service provider: Traxx Medical Holdings LLC, an Austin company that provides neuromonitoring during spinal surgery. Neuromonitoring uses electrical signals to detect when a surgeon is causing damage to nerves.

Medical service: Cannon was born with a rare spinal condition that had caused chronic pain and muscle weakness since she was a child. In December 2017, she had successful spinal surgery to correct the problem. Her surgeon requested neuromonitoring during the operation.

What gives: Neuromonitoring made sense for the type of surgery Cannon had. The bill did not. Cannon should have been warned long before her surgery that the neuromonitoring company would be an out-of-network provider whose fees might not be covered by her insurer.

At first, she was baffled by the billing information that Blue Cross sent her. "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 says.

The statement listed four separate charges from the day of her surgery. Each was described as a "diagnostic medical exam." Together, they came to $94,031.

Blue Cross said the covered amount was $815.69 — minus a $750 deductible and $26.27 for coinsurance — and informed Cannon she might have to pay the balance — $93,991.58

"I was shocked," she says. Chiumento was outraged.

"As soon as I saw that, I thought it was a scam," he says.

The bill had come from an Austin company called Traxx Medical Holdings LLC. Traxx did not respond to emails, phone calls and a fax seeking comment on the charge.

The company's website shows that Traxx provides a service called intraoperative neurophysiological monitoring, which evaluates the function of nerves during surgery. The goal is to help a surgeon avoid causing permanent damage to the nervous system.

There is an ongoing debate about whether neuromonitoring is needed for all spinal surgery. But it is standard for a complicated operation like the one Cannon had, says Richard Vogel, president of the American Society of Neurophysiological Monitoring.

On the other hand, a $94,000 charge for the service can't be justified, Vogel says.

"You're not going to meet anybody who believes that a hundred thousand dollars or more is reasonable for neuromonitoring," Vogel says.

Most neuromonitoring companies charge reasonable fees for a valuable service and are upfront about their ownership and financial arrangements, he says. But some companies are greedy and submit huge bills to an insurance company, hoping they won't be challenged, he adds.

Even worse, "some neuromonitoring groups charge excessive fees in order to gain business by paying the money back to surgeons," Vogel says.

Last year, Vogel's group published a position statement condemning these "kickback arrangements" and other unethical business practices.

It is unclear whether Traxx, the company that provided neuromonitoring for Cannon, has any financial arrangements with surgeons. Cannon's surgeon did not respond to requests for comment.

The size of the fee for Cannon's neuromonitoring was only part of the problem. The other part was that Traxx — unlike her hospital, surgeon and anesthesiologist — had no contract with Blue Cross and Blue Shield of Texas.

As an out-of-network provider, the company could set its own fees and try to collect from Cannon any amount it didn't get from her insurer.

Blue Cross and Blue Shield of Texas said it doesn't comment on problems affecting individual members. But the insurer did offer a general statement by email about the problem:

"Unfortunately, non-contracted providers can expose our members to significantly greater out-of-pocket costs. 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."

One thing working against Cannon is that she is pretty sure that just before surgery, she signed a paper that authorized the out-of-network neuromonitoring.

"It was 4:30 in the morning and you're like, 'OK, let's get this over with,' " she recalls.

Getting consent in the hospital may be legal, but it's not reasonable, says Dr. Arthur Garson Jr., who directs the Health Policy Institute at the Texas Medical Center in Houston.

For example, a patient might be having a heart attack, Garson says. "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.' "

The Texas Legislature passed a bill in May to protect patients from the sky-high bills this practice can produce. And Congress is considering similar legislation.

These are small steps in the right direction, Garson says.

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

The Texas legislation is expected to take effect later this year but affects only bills that occur after it becomes law. So that $94,000 figure is never far from Cannon's mind, even as she and Chiumento plan their wedding.

"Every time I go out and I collect the mail, I'm wondering, 'Is this the day it's going to show up and we're going to have to deal with this?' " she says.

The takeaway: Neuromonitoring during complex surgery involving the spine can help prevent inadvertent damage. But monitoring may be unnecessary for lower-risk back operations, like spinal fusion.

It is strange that neuromonitoring is charged as a separate service, rather than part of the spine surgery. Cardiac monitoring is not charged separately during bypass surgery, for example.

When considering spine surgery, ask your doctor whether neuromonitoring will be part of the procedure. If so, will it be billed separately? Try to find out the name of the provider and get an estimate of the cost beforehand.

Check with your insurer to determine if the neuromonitoring provider is within your network and to make sure the estimated charge will be covered.



Copyright 2020 NPR. To see more, visit https://www.npr.org.

NOEL KING, HOST:

A major operation means a lot of medical bills. There is the surgeon. There's the hospital. There's the anesthesiologist. But a growing number of patients are also seeing big charges for a little-known service that is often not covered by insurance. NPR's Jon Hamilton is here to talk about this in our latest bill of the month. Hey, Jon.

JON HAMILTON, BYLINE: Hey, Noel.

KING: So you are here with another horrendous medical bill. What have you got?

HAMILTON: Well, I do have horrendous medical bill. So imagine you just found out that you might owe $94,000 for a medical service you didn't even know existed.

KING: I would be terrified and very upset.

HAMILTON: Yeah. Well, that was pretty much the reaction of Liv Cannon. She's a woman who lives in Austin. I went to speak with her a couple of weeks ago. And she lives in this cute little cottage with her fiance, Cole Chiumento. And they've got two dogs, who I must say are super friendly.

(SOUNDBITE OF GATE SQUEAKING)

HAMILTON: You must be Liv.

LIV CANNON: I am, yeah.

HAMILTON: You must be Cole.

COLE CHIUMENTO: Yeah.

CANNON: (Laughter).

HAMILTON: And these must be...

CANNON: These are - this is Lyndon...

CHIUMENTO: Lyndon.

CANNON: ...And this is Jolene.

HAMILTON: These days, Liv is spending a lot of time in her garden.

CANNON: Here we have tomatillos, eggplant, and then my cherry tomatoes are in here.

HAMILTON: Liv says gardening is a big deal for her because it was pretty much impossible before she had back surgery.

CANNON: It's a lot of bending over, and it's a lot of crouching. And none of that I could ever do before. And it's still hard for me.

HAMILTON: Until she was 24, Liv experienced chronic pain and debilitating muscle weakness.

CANNON: There was a lot of pain in my legs, which I can now recognize as nerve pain. There was a lot of pain in my back, which I thought was, you know, just something that everybody lived with.

HAMILTON: Liv saw lots of doctors over the years, but they couldn't explain what was going on. She'd pretty much given up on finding an answer until Cole pushed her to try one more time.

CHIUMENTO: It never improved. It never got better. That just didn't - that didn't sound right to me.

HAMILTON: So Liv went to a specialist, who ordered an MRI of her spine. A few days later, her phone rang.

CANNON: Is this Olivia? Yes. We found something on your MRI. It's diastematomyelia with tethered cord syndrome, and the tumor's benign. And I'm like, sorry, what - tumor?

HAMILTON: Liv had been born with a rare condition that causes a part of the spinal cord to split in two. In her case, it also led to a tumor that trapped her spinal cord, causing it to stretch as she grew. In December of 2017, a neurosurgeon opened up her spinal column and freed the cord.

CANNON: I think it was day three after my surgery, I could feel the difference. There was just a pain that I had always had that wasn't there anymore.

HAMILTON: As she recovered, Liv saw lots of huge medical bills. But they were all covered by her insurance plan - all except one, which arrived almost a year after the operation.

CANNON: It wasn't exactly a bill. It was one of those things from the insurance company that says, this is what we cover, and this is the amount that you might owe your provider.

HAMILTON: The amount? Ninety-three thousand, nine hundred and ninety-one dollars and 58 cents.

CANNON: I was shocked.

HAMILTON: Her fiancee was outraged.

CHIUMENTO: As soon as I saw that, I thought it was a scam.

HAMILTON: It wasn't just the amount. The bill had come from an Austin company called Traxx Medical Holdings. Traxx provides a service that monitors the function of nerves during surgery. The goal of this neuromonitoring is to help a surgeon avoid damaging a nerve. But unlike Liv's surgeon and hospital, Traxx was not part of her insurance company's network, so the bill was her responsibility. Cole says that's just wrong.

CHIUMENTO: I don't see how they could continue to put people in this sort of financial peril and have it ultimately be on the up-and-up.

HAMILTON: Traxx did not respond to requests for comment. Liv's insurance company at the time, Blue Cross and Blue Shield of Texas, agreed to cover about $800, or roughly 1%, of the charge. And Liv is pretty sure that, just before surgery, she signed a paper that authorized the out-of-network neuromonitoring. Dr. Arthur Garson Jr. directs the Health Policy Institute at the Texas Medical Center in Houston. He says getting a patient's consent in the hospital may be legal, but it's not reasonable.

ARTHUR GARSON JR: You're having your heart attack. There you are flat on your back. 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.

HAMILTON: In May, the Texas legislature passed a bill to protect patients from the sky-high charges this practice can produce. And Congress is considering similar legislation. Garson says these are small steps in the right direction.

GARSON JR: Asking the individual patient to make that decision even when they're not sick, I think, is difficult. And maybe we ought to figure out some better way to do it.

HAMILTON: The Texas legislation is expected to take effect in September, and it won't help Liv Cannon. So she says that $94,000 figure is never far from her mind.

CANNON: I still think about it. Every time I go out, and I collect the mail, I'm, like, wondering is this the day that it's going to show up and that we're going to have to deal with this.

KING: So Jon, if Liv does end up getting this $94,000 bill, is she going to pay it?

HAMILTON: She says no. She says she and Cole plan to fight it.

KING: How common is this, that people will get a big medical bill for something - for a service that they didn't know they were getting?

HAMILTON: Well, it's a lot more common than it used to be. And especially in neuromonitoring, this is a field that was established decades ago. But in the last few years, it has expanded greatly. And often, it's a service that is what they call an out-of-network service where patients are getting surprise bills later on.

KING: All right. So how can people ensure that this doesn't happen to them? How can they protect themselves?

HAMILTON: Well, if you're going to be getting surgery, especially spinal surgery, and, you know, it's a thing where neuromonitoring may be called for, you want to find out whether you're going to have it. And if your doctor says, yes, I'm going to order neuromonitoring, then you want to find out who is providing it. Look up the company. Are they a private company? Are they part of your insurance network? Because if they're not, you might be the one that has to pay out of pocket.

And the final piece of advice I got from insurers is if you get a bill that you think is outrageous, go to your insurance company. They may be able to negotiate on your behalf to get it eliminated or reduced.

KING: That's interesting. But also, that's a lot of work. Are consumers going to get any help with this?

HAMILTON: Well, in some places they are. A number of states including Texas are in the process of passing legislation or have passed legislation to protect consumers from surprise medical bills, not just for neuromonitoring, but anything like this that's out of network that you didn't know about. The question is whether there's going to be federal legislation. And there is a bill before Congress that would offer some of these same consumer protections. Whether it passes or not, we'll see.

KING: NPR's Jon Hamilton. Thanks, Jon.

HAMILTON: You're welcome.

(SOUNDBITE OF LOESS' "BRUMAL") Transcript provided by NPR, Copyright NPR.