Article Summary: Surgical Assistant’s presence during a surgery leads to a costly
surprise medical bill.
By Markian Hawryluk, KHN, Jul 22, 2020
Izzy Benasso was playing a casual game of tennis with her father on a summer
Saturday when she felt her knee pop. She had torn a meniscus, one of the friction-
reducing pads in the knee, locking it in place at a 45-degree angle.
Although she suspected she had torn something, the 21-year-old senior at the
University of Colorado in Boulder had to endure an anxious weekend in July 2019
until she could get an MRI that Monday.
“It was kind of emotional for her,” said her father, Steve Benasso. “Just sitting there
thinking about all the things she wasn’t going to be able to do.”
At the UCHealth Steadman Hawkins Clinic Denver, the MRI confirmed the tear, and
she was scheduled for surgery on Thursday. Her father, who works in human
resources, told her exactly what to ask the clinic regarding her insurance coverage.
Steve had double-checked that the hospital; the surgeon, Dr. James Genuario; and
Genuario’s clinic were in her Cigna health plan’s network.
“We were pretty conscious going into it,” he said.
Isabel met with Genuario’s physician assistant on Wednesday, and the following day
underwent a successful meniscus repair operation.
“I had already gotten a ski pass at that point,” she said. “So that was depressing.” But
she was heartened to hear that with time and rehab she would get back to her active
Then the letter arrived, portending of bills to come.
The Patient: Izzy Benasso, a 21-year-old college student covered by her mother’s
Cigna health plan.
The Total Bill: $96,377 for the surgery was billed by the hospital, Sky Ridge
Medical Center in Lone Tree, Colorado, part of HealthONE, a division of the for-
profit hospital chain HCA. It accepted a $3,216.60 payment from the insurance
company, as well as $357.40 from the Benassos, as payment in full. The surgical
assistant billed separately for $1,167.
Service Provider: Eric Griffith, a surgical assistant who works as an independent
Medical Service: Outpatient arthroscopic meniscus repair surgery.
What Gives: The Benassos had stumbled into a growing trend in health care: third-
party surgical assistants who aren’t part of a hospital staff or a surgeon’s practice.
They tend to stay out-of-network with health plans, either accepting what a health
plan will pay them or billing the patient directly. That, in turn, is leading to many
Even before any other medical bills showed up, Izzy received a notice from someone
whose name she didn’t recognize.
“I’m writing this letter as a courtesy to remind you of my presence during your
surgery,” the letter read.
It came from Eric Griffith, a Denver-based surgical assistant. He went on to write
that he had submitted a claim to her health plan requesting payment for his services,
but that it was too early to know whether the plan would cover his fee. It didn’t talk
dollars and cents.
Steve Benasso said he was perplexed by the letter’s meaning, adding: “We had never
read or heard of anything like that before.”
Surgical assistants serve as an extra set of hands for surgeons, allowing them to
concentrate on the technical aspects of the surgery. Oftentimes other surgeons or
physician assistants — or, in teaching hospitals, medical residents or surgical fellows
— fill that role at no extra charge. But some doctors rely on certified surgical
assistants, who generally have an undergraduate science degree, complete a 12- to
24-month training program, and then pass a certification exam.
Surgeons generally decide when they need surgical assistants, although the Centers
for Medicare & Medicaid Services maintains lists of procedures for which a surgical
assistant can and cannot bill. Meniscus repair is on the list of allowed procedures.
A Sky Ridge spokesperson said that it is the responsibility of the surgeon to
preauthorize the use and payment of a surgical assistant during outpatient surgery,
and that HealthOne hospitals do not hire surgical assistants. Neither the assistant
nor the surgeon works directly for the hospital. UC School of Medicine, the surgeon’s
employer, declined requests for comment from Genuario.
Karen Ludwig, executive director of the Association of Surgical Assistants, estimates
that 75% of certified surgical assistants are employed by hospitals, while the rest are
independent contractors or work for surgical assistant groups.
“We’re seeing more of the third parties,” said Dr. Karan Chhabra, a surgeon and
health policy researcher at the University of Michigan Medical School. “This is an
emerging area of business.”
And it can be lucrative: Some of the larger surgical assistant companies are backed
by private equity investment. Private equity firms often target segments of the health
care system where patients have little choice in who provides their care. Indeed,
under anesthesia for surgery, patients are often unaware the assistants are in the
operating room. The private equity business models include keeping such helpers
out-of-network so they can bill patients for larger amounts than they could negotiate
from insurance companies.
Surgical assistants counter that many insurance plans are unwilling to contract with
“They’re not interested,” said Luis Aragon, a Chicago-area surgical assistant and
managing director of American Surgical Professionals, a private equity-backed group
Chhabra and his colleagues at the University of Michigan recently found that 1 in 5
privately insured patients undergoing surgery by in-network doctors at in-network
facilities still receive a surprise out-of-network bill. Of those, 37% are from surgical
assistants, tied with anesthesiologists as the most frequent offenders. The
researchers found 13% of arthroscopic meniscal repairs resulted in surprise bills, at
an average of $1,591 per bill.
Colorado has surprise billing protections for consumers like the Benassos who have
state-regulated health plans. But state protections don’t apply to the 61% of
American workers who have self-funded employer plans. Colorado Consumer Health
Initiative, which helps consumers dispute surprise bills, has seen a lot of cases
involving surgical assistants, said Adam Fox, director of strategic engagement.
Resolution: Initially, the Benassos ignored the missive. Izzy didn’t recall meeting
Griffith or being told a surgical assistant would be involved in her case.
But a month and a half later, when Steve logged on to check his daughter’s
explanation of benefits, he saw that Griffith had billed the plan for $1,167. Cigna had
not paid any of it.
Realizing then that the assistant was likely out-of-network, Steve sent him a letter
saying, “we had no intention of paying.”
Griffith declined to comment on the specifics of the Benasso case but said he sends
letters to every patient, so no one is surprised when he submits a claim.
“With all the different people talking to you in pre-op, and the stress of surgery, even
if we do meet, they may forget who I was or that I was even there,” he said. “So the
intention of the letter is just to say, ‘Hey, I was part of your surgery.’”
After KHN inquired, Cigna officials reviewed the case and Genuario’s operative
report, determined that the services of an assistant surgeon were appropriate for the
procedure and approved Griffith’s claim. Because Griffith was an out-of-network
provider, Cigna applied his fee to Benasso’s $2,000 outpatient deductible. The
Benassos have not received a bill for that fee.
Griffith says insurers often require more information before determining whether to
pay for a surgical assistant’s services. If the plan pays anything, he accepts that as
payment in full. If the plan pays nothing, Griffith usually bills the patient.
The Takeaway: As hospitals across the country restart elective surgeries, patients
should be aware of this common pitfall.
Chhabra said he’s hearing more anecdotal reports about insurance plans simply not
paying for surgical assistants, which leaves the patient stuck with the bill.
Chhabra said patients should ask their surgeons before surgery whether an assistant
will be involved and whether that assistant is in-network.
“There are definitely situations where you need another set of hands to make sure
the patient gets the best care possible,” he said. But “having a third party that is
intentionally out-of-network or having a colleague who’s a surgeon who’s out-of-
network, those are the situations that don’t really make a lot of financial or ethical