American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Statement on Billing of Surgical Fees for Extracorporeal Shock Wave Lithotripsy (ESWL) Treatment of Patients with Calculous Disease

The American College of Surgeons has received a number of inquiries regarding the ethics of certain fee arrangements for patients being treated by extracorporeal shock wave lithotripsy (ESWL). In many instances, a corporation, or other entity, has been established to purchase and operate the ESWL equipment. A variety of arrangements have been developed to handle the billing of fees associated with the procedure.

In some situations, the corporation or entity which owns or operates the ESWL equipment, and seeks patient referrals, offers to bill the patient a single fee for all aspects of the procedure. The fee is then to be distributed, with a standard percentage of the fee for all patients to be paid to the referring physician, who provides the preoperative evaluation and postoperative care of the patient and may provide special postoperative reports to the ESWL entity. The offer may include a commitment by the ESWL entity not to increase the fee paid to any referring physician without similarly raising the fee paid to all referring physicians. These payment arrangements are not disclosed to the patient. This type of fee arrangement is considered by the American College of Surgeons to be a form of "fee-splitting."

The College has long supported the principle that a patient should have full knowledge of who is providing the professional service and the charge for this service. This is best achieved when the referring physician, and any other physician rendering ESWL-associated professional services, makes a determination of the appropriate fee for each individual patient and sends the patient a statement for these professional services.

If all ESWL services are billed in a single statement, full disclosure should be made of the amount of the fee that will be paid to each physician who has rendered professional services in connection with the procedure.

Reprinted from Bulletin of the American College of Surgeons
Vol. 71, No. 4, Page 21, April 1986