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President's Message - August 2019

Posted By Richard W. Vogel, Wednesday, July 31, 2019


My last President’s Message was in June. This has been a busy month. On the personal front, I moved to a new home and took a week’s vacation to unplug and recharge. Now, I’m back to work for you.

I want to give you an update on some of the things we’re working on, as well as make some comments related to the NPR storyabout IONM that broke on June 17th.

Here’s a bullet point list of some projects we’re working on presently.

  • Reviewing contracts for upcoming meetings. Our management partner, Affinity Strategies, is working hard trying to secure locations and hotels. In that process, our Executive Committee is working to select the best locations and review potential contracts with hotels.
    • As you know, a primary goal of mine is to get our hotel prices down and make them affordable for all.
    • Our 2020 Annual Meeting has been moved from Chicago to St. Louis. It will be held May 15-17, 2020. 
  • Collaborating with other societies, like ASET, to coordinate various projects that we’re collaborating on. One example is patient awareness and advocacy.
  • Our Taskforce on Diversity is off the ground and presently being coordinated by Dr. Tara Stewart
  • We also launched a “Sponsor Taskforce” to seek input from our industry partners. This taskforce is being led by Leah Hanson. They are presently working on our 2020 prospectus.
  • I’ve been working with Affinity Strategies to update our branding and communications.
    • We’ll no longer bombard you with emails. You can expect to see e-blasts from us approximately every 2 weeks. The President’s Message will come in the first e-blast of the month.
    • You’ll get a reminder to register on the day of a webinar.
    • Everything that comes from the ASNM will be branded the same and look clean and consistent.
  • We’ve made a few changes to the membership application:
    • Removed CV requirement for membership application. Students must still upload proof of student status in a relevant program.
    • I am personally reviewing every question on the membership application and we will update/alter them as needed to ensure we are attracting a diverse membership. Remember, the ASNM is open to anyone with an interest in IONM, regardless of background, education, training, experience or role in IONM.
  • We’ve made a few changes to the website:
    • We included headshots on leadership page so you can see who represents you.
    • While it is in the very early stages, we are working to develop a section of the website dedicated to educating patients about IONM. We have some awesome volunteers working on this project. I expect it to take the better part of a year to complete. 

Now, I’d like to spend the rest of my message commenting on the NPR Story:

Unless you’ve lived in a cave for the last two months, I’m sure you are aware of the story that NPR broke about a patient in Texas receiving an Explanation of Benefits for IONM to the tune of $94K.

The first thing I want to say is my heart goes out to the patient, Liv Cannon, and her fiancé, Cole Chiumento. It’s bad enough having a complex spine disorder and a complex spine surgery, but to receive a large EOB is certainly scary for anyone. The anxiety Liv and Cole must have felt wondering if they would ever receive a bill, well, I can only imagine.

The second thing I want to say is that I spoke to NPR for about 30 minutes, but they only used 2 quotes from me. Both of them were used out of context. I want to give you a couple of examples taken directly from the article. What you see below in italicsis what NPR reported in print. Anything in [brackets]is my comment on that particular statement.

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[There are no quotation marks here. So, this is not a quote. This is a summary of a conversation I had with the reporter in which I talked about regional differences in the use or nonuse of IONM by surgeons, and how some surgeons feel that lower risk cases do not require IONM. Regardless, I stand behind the accuracy of this statement as it is printed.].

On the other hand, a $94,000 charge for the service can't be justified, Vogel says. [Again, no quotation marks, not a quote. This is the reporter’s interpretation of the quote below].

"You're not going to meet anybody who believes that a hundred thousand dollars or more is reasonable for neuromonitoring," Vogel says. [This statement is surrounded by quotation marks. This is a direct quote, and the context of this quote was related to the cases in Colorado which the reported asked me about. As an independent individual, I stand behind this statement. The ASNM, however, is not in a position to determine what one can or cannot charge for IONM. If you want to read why, you’ll have to read my statement that I gave to NPR in the paragraphs that follow below].

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. [Again, no quotation marks, not a quote. This is a summary. I stand behind the accuracy of this comment].

Even worse, "some neuromonitoring groups charge excessive fees in order to gain business by paying the money back to surgeons," Vogel says. [This statement is surrounded by quotation marks. You can review my written statement for context. I stand behind the accuracy of this statement, too.].

Last year, Vogel's group published a position statement condemning these "kickback arrangements" and other unethical business practices. [Again, the primary context was the Colorado story.].


Now that I’ve given you some info about my quotes, I thought it might be helpful to our members to read some of what I actually said to NPR, so you can see the context for some of my comments, AND so you can see all the good stuff they never even used: What you see in bold below are the questions I was asked, and then you can see below each how I responded.

What is the evidence that neuromonitoring (IONM) is beneficial for patients?

In general, the evidence is quite good in support of neuromonitoring’s benefits across the wide range of surgical procedures in which it is used. Aside from any risk to the nervous system coming directly from the surgical procedure, studies also show that IONM can detect and prevent positioning related injuries that may result from a patient laying in the same position for a long time during surgery. So, the utility of neuromonitoring is greater than what many people initially consider.

Recently, a number of studies have been published in prestigious journals questioning the utility and value of neuromonitoring, but those studies are so fundamentally flawed, the very fact that they were even published is a testament to how broken our peer review system is in the scientific and medical literature. At the end of the day, these studies have little merit, but their publication brings to light some important considerations regarding evidence for neuromonitoring. Specifically, evaluating the neuromonitoring literature is challenging because there’s tremendous variability in how surgeons use it. This heterogeneity confounds many comparative studies. Also, critics argue that there are no class I studies evaluating neuromonitoring, but the same is true for many medical interventions, including spinal decompression and fusion surgery. In order to develop class I studies, patients would have to be randomized to groups receiving IONM or no IONM in high risk surgery, and the ethics of withholding a treatment which is largely considered standard is questionable. 

Which patients need neuromonitoring?

Neuromonitoring is performed in a wide variety of surgeries, including brain, spine, cardiothoracic and ear/nose/throat, just to name a few. All of these procedure pose some risk to the patient’s nervous system, which can result in weakness, paralysis, loss of sensation, loss of hearing, loss of sight, loss of bowel/bladder control, etcetera. So, it may be indicated for any surgical procedure in which the patient’s nervous system is at risk. 

What has led to the rapid expansion of neuromonitoring?

Many people have argued that use of neuromonitoring expanded secondary to the availability of personnel created when we introduced the telemedicine model of one physician remotely supervising many technologists, but there’s no evidence to support this. Indeed, a highly qualified and educated workforce was available long before this model was introduced.

The real drivers of the expansion are education and liability. Regarding education, many surgeons now understand the utility and value of neuromonitoring for protecting their patients. Whereas neuromonitoring started in spine surgery, it has now expanded to include surgery on other parts of the body. The number of surgeries performed in the US continues to grow, and the types of surgeries that neuromonitoring benefits continues to expand as well.

Regarding liability, there’s tremendous pressure on surgeons and hospitals from the medicolegal community. There’s always a fear of being sued. Using neuromonitoring is thought to reduce a surgeon’s liability, so they use it for their own protection.

How much does neuromonitoring typically cost?

I think we need to break this down two different ways, so I going to rephrase your question both ways and answer each independently:

How much does it cost to perform the service?

We can start by asking how much does it cost a neuromonitoring company (or hospital) to perform the service on a single patient. Neuromonitoring is like any other business where you have salaries, equipment, supplies, travel and overhead. The break-even amount can vary significantly from one group to another. Hospitals and insurance companies often want to pay as little as possible, but they’re just bargaining for lower quality patient care. The unfortunate consequence of driving down prices is a less educated and competent work force using lower quality equipment. So, neuromonitoring can be done inexpensively at the risk of lower quality patient care, or it can be more expensive to get expert neurophysiologists working in the operating room with the most advanced monitoring equipment. 

How much is the average cost to consumer (payor)?

The next question is, how much should it cost the insurance company, or the patient. I have to start by saying that I’m not an expert in medical billing, which is extremely complex, and neuromonitoring is no exception. The cost to consumer (payor) can vary simply depending on the type of monitoring performed and the length of surgery, but these factors alone do not account for the exorbitant charges that are billed for neuromonitoring. Those charges come from a fee schedule that each neuromonitoring group generates to determine what they will charge insurance companies for performing the service. This is based on CPT codes (current procedural terminology) that identify which neuromonitoring tests were used. The usual, customary and reasonable fees associated with these codes are updated annually in a medical fee manual published by Practice Management Information Corporation. For each code, PMIC publishes rates in the 50th, 75thand 90thpercentile based on national averages. In developing a fee schedule, neuromonitoring groups use these numbers, and adjust them by their geographic location. So, there is a basis for developing specific fees for specific neuromonitoring tests. The problem is that some groups are greedy, and they can just double or triple the end product to get more money, and insurance companies are simply unaware or don’t care. The other method that some companies use to develop their fee schedule is to see what Medicare recommends from their fee schedule, then charge a multiple. The basis for determining the multiple is beyond the range of my expertise. 

There have been news reports of some patients receiving very high bills for neuromonitoring. Is that a problem in the field?

The first thing we have to do is differentiate between what is a bill, and what is not a bill. Most frequently, patients receive something in the mail from their insurance company called an Explanation of Benefits. It’s a summary of charges and coverages, and it always says somewhere “this is not a bill”, but patients often get scared and come to expect an impending bill when they see some amount of money listed under a section entitled “your responsibility” or “provider may bill you”. The amount listed is just the difference between what the doctor charged the insurance company and what the insurance company is contracted to pay. Attempting to collect that difference from the patient is called “balance billing”, which is prohibited in some states, but not all. So, patients may or may not be responsible for some portion of the balance. How much the patient actually owes depends mostly on the patient’s co-insurance, deductible and co-pay. It’s all related to the patient’s individual insurance plan. So, if the patient owes anything, it may be far less than expected.

In rare circumstances, patients do actually get very large bills. Unfortunately, many patients these days have high deductible plans with no OON benefits. So, they’re going in to have what is often a very expensive procedure with little in the way of financial protection.  The best thing a patient can do is contact the doctor and the insurance company and ask them to advocate for you. There are ways to reduce costs. Even then, most neuromonitoring groups don’t put patients into collection unless they received a check from the insurance company and failed to turn it over to the rendering provider.

The biggest concern for our field is the fact that some groups charge excessive fees in order to gain business by paying the money back to surgeons. It’s a big enough problem that the ASNM took the bold step last year of publishing a position statement on business practices in neuromonitoring. We’re not in a position to tell providers how much they can charge insurance companies, but we are in a position to express concern over why they charge such high fees and what they do with the money. A growing problem in the US right now is groups paying surgeons a kickback to use neuromonitoring. So, some percentage of that patient’s large bill is funneled back to the surgeon as an incentive to use a specific neuromonitoring group. While the practice is technically legal in a few states, the AMA is clear in their view that the practice is unethical, and we feel the same way. 

How and when should patients be informed that neuromonitoring services will be an out-of network service?

Best case scenario, the patient should be informed by the surgeon or hospital at the time when the surgery is booked. Unfortunately, 99% of IONM is considered elective. So, surgeons and hospitals may fear that, if they tell the patient IONM is OON, the patient will choose not to have their surgery at that location. Hospitals/surgeons are afraid of losing the business. So, the patient is often informed in the minutes just before surgery when they sign the consent for neuromonitoring.

The most unfortunate part of all this is that the OON status of most neuromonitoring companies is actually the fault of the insurance companies who are supposed to be advocating for their patients. Many IONM groups actually try to go in network, but the insurance companies only accept a limited number of neurologists in their network, most of whom don’t do neuromonitoring. So, a neuromonitoring group attempting to bring their neurologists in network is often denied.

On top of that, the fees are driven up by insurance companies’ refusal to negotiate with neuromonitoring groups, which would only make charges more reasonable for all. That alone could save the insurance industry tens of millions of dollars per year.

Neuromonitoring’s pervasive OON statues is mostly the result of the fact that insurance companies don’t understand IONM, and they’re not willing to listen.

How can consumers avoid a surprise bill for neuromonitoring?

If the patient actually receives a bill in the mail, the best thing to do is to call the provider. They can usually help to reduce the cost by working with the patient to appeal to the insurance company to reprocess the claim at in-network prices. This could save hundreds or thousands of dollars.

In terms of actually avoiding a surprise bill, some states have laws against surprise bills, while others do not. So, it’s difficult to know if you are protected. The best thing a patient can do is ask his/her surgeon which ancillary services will be used during surgery. Neuromonitoring is just one type of ancillary service. From there, the patient can find out of the provider is in-network, or ask their insurance company what they can do to process the claim at in-network prices. 


So, that’s my President’s Message for August 2019. I hope you’re all enjoying your summer. I’ll be back in September with another update from the front lines.

Tags:  President's Message 

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