This game with friggin' surgical "assistants", whether they be physicians, NP's, PA's, surgical assistants, or surgical techs, is one that really pisses me off. Some procedures need an assistant - no doubt. But some are there strictly so they can bill for something whether needed or not. Many times, an assistant is totally unnecessary. Lap appy? No. Port placement? Hell no. Yet I see assistants with these cases all the time. Why? Because surgeons are spoiled. In my early career, assistants were almost unheard of. Nearly every procedure was done with the surgeon and the scrub tech. That was it.
Among other games that are played...
When a patient signs their mountain of paperwork for surgery, very few actually look at what they are signing. Physician offices will slip in a "consent" for a surgical assistant - that consent includes a clause that the assistant may or may not be in network, but that the patient agrees to pay the bill regardless. It borders on fraud - it's rarely mentioned by the surgeon ahead of time.
Many areas, including mine, use "certified surgical assistants". Some of them are very talented, including some who are actually IMG's that can't get jobs as physicians in the US. These assistants, at least in my state, are unlicensed. In some cases, they have an agreement with the hospital. Medicare won't pay for them, but since it's admittedly difficult to do some procedures without an assistant, the hospital sometimes pays a flat fee for the assistant as an enticement for the surgeon to work there.
In other cases, the assistant, or their office, send in a bill to insurance companies for their services. Some insurance companies will pay, some won't. They don't ever appeal with the insurance companies (unless they have a network agreement, which most don't). However, if they have that little "consent" from the physician office, they then turn around and balance bill the patient.
My wife had a lap chole several years back. The surgeon got his usual discounted fee. Really not that bad for less than a 45 minute procedure and one post-op office visit that took five minutes. The unlicensed surgical assistant received more in payment than the anesthesia team (anesthesiologist and anesthetist). Absolutely absurd.