BACK SURGERY COST

Back Surgery Cost

Curious about the cost of spine surgery? The answer is not as straightforward as you may think. With over 30 years of spine care experience the team at AOMSI diagnostics has put together the below information to help shed light on the cost of spine surgery.

Selecting a Surgeon

First and foremost, spine surgery should only be considered as a last resort. Patients should exhaust all conservative treatment options prior to considering spine surgery. Conservative care and conservative treatment options include but are not limited to physical therapy, chiropractic, acupuncture, and pain management.  Each of these conservative therapies, should be exhausted to the fullest extent.  Once conservative therapies are exhausted, the next step that is crucial to patient care is selecting the appropriate spine surgeon.

Spine surgeons seem to be a dime a dozen these days. It's no coincidence that spine surgery drives a significant amount of revenue for traditional orthopedic surgeons, thus the influx of providers who perform spine surgery.  When selecting a spine surgeon it is important to consider their background, the number of surgeries they've performed and what they specialize in.  It is important to select a surgeon who specializes in spine surgery. After all, you only get one spine.  

Once you've identified a spine surgeon who specializes in spine specifically, you'll want to get an idea of the number of procedures they've performed - specifically the procedure that you have been recommended. Once you've identified the right surgeon and have a grasp of the number of procedures they've performed (specifically your procedure) the next step is to ask your surgeon specifically what the success rate will look like for this particular procedure. Ask your surgeon how they define success? Does this definition of success align with your definition of success? Just because the spine looks pretty on an MRI and everything is aligned doesn't necessarily mean you'll be out of pain and back to your life. Finally, you want to consider if you have insurance, if the provider is in-network or out-of-network with your particular insurance plan.

If you have insurance, you can read the additional sections detailing the ins and outs of out-of-pocket cost with your particular insurance plan.  If you do not have insurance, skip to the section that's listed as no insurance.

Insurance

When using insurance for spine surgery, there are usually two options in-network and out-of-network. In-network means that the health care provider has agreed to a contract with your health insurance plan. Out-of-network means that the health care provider has not agreed to a contract with your health care health care plan.  While in-network options may have a lower out-of-pocket cost, they do not necessarily indicate that the provider is a better quality if they are in-network as opposed to out-of-network.

For both in-network and out-of-network plans it is important for the spine surgery to be pre-authorized or pre-approved through your health insurance. Far too often we see surgeries that are performed without pre-authorization or pre-approval and patients are left to fight for approval after the surgery is completed. This is a risky maneuver as the insurance can certainly deny approval for surgery and patients are left with the full out-of-pocket cost.

Once pre-approval or pre-authorization is obtained, the next step is to look at your deductible. Each insurance policy will have a specific deductible for both in-network and out-of-network plan. Your deductible is the out-of-pocket cost your insurance requires you to meet before your insurance plan kicks in. For example, most plans are set up as follows: $5000 deductible once your deductible is met for the year, insurance will pay 80% of billed charges.  For in-network plans the percentage paid on billed charges is usually higher than that of the out-of-network side of your plan.

See below for a quick example:

In-Network deductible: $5000 once deductible met plan pays 80%

Out-of-network deductible: $8000 once deductible met plan pays 80%

In the example above, you will see that the deductible for in-network is lower than the deductible for out-of-network. As mentioned above, in-network means that the provider has agreed to a contract with the insurance company. Because the provider is in-network the insurance plans typically will want to steer patients in the direction of staying in-network. To sum up, the deductible is the amount of out-of-pocket cost the patient is responsible for before the insurance plan kicks in. 

The next item for most insurance is in-network and out-of-network out-of-pocket maximum. The out-of-pocket maximum is the maximum amount a patient is responsible for in one calendar year.  Good news! Your deductible will go towards your out-of-pocket maximum.

In the example above, the patient has a $5000 deductible.  Once met, the plan pays 80%. The patient is responsible for the remaining 20% making up the full total of 100% of provider billed charges.  Using the same example let's say that this plan has an in-network out-of-pocket maximum of $10,000 for one calendar year.  Once that out-of-pocket maximum is met the plan pays at 100%.  

The out-of-pocket maximum can be different for in-network and out-of-network plans. However, usually the out-of-pocket pocket maximum will apply to both in-network and out-of-network. 

For example, let’s say throughout the calendar year a patient goes in for an in-network procedure of $5000.  Using this example, the $5000 deductible would be met for in-network, and the plan will pay 80% of bill charges. Let's say the same patient has another $5000 procedure performed in the same calendar year. The plan would pay $4000 which is 80% of the $5000 procedure the patient would be responsible for $1000 in out-of-pocket costs. In total for one calendar year, the patient has paid $6000 and out-of-pocket costs. As stated above, this particular patient has an out-of-pocket pocket maximum of $10,000 for one calendar year. This means that if the patient has additional in-network procedures performed, the deductible has been met at 100%, however, there is still $4000 remaining on the out-of-pocket maximum until the plan pays at 100% of bill charges.

Unfortunately, health insurance and out-of-pocket cost are not as black and white. So a specific back surgery cost with insurance takes a little bit of effort to understand for a procedure.  

A few things to take away from the above example, when identifying the back surgery cost with insurance it is important to obtain the following:

·      How much will the provider be billing for the procedure?

·      Make sure the procedure is pre-authorized.

·      Is the provider in-network or out-of-network with your insurance plan?

·      What are your specific plans in-network and out-of-network benefits? (deductible and out-of-pocket maximum)

·      How much have you met for your plan in the calendar year?

Without Insurance

The cost of back surgery without insurance is much more simple and straightforward.  Your health care provider will typically have a billed charge (this is the charge that they send to the insurance anticipating that the insurance will discount that full billed charge) and the provider will have a cash pay rate for patients who do not have insurance. The cash pay rate should be less than the typical billed charge.  This charge will vary by provider however most providers should be able to make arrangements for patients paying the cash pay rate. If the provider office is unable to finance in-house, there are several other medical financing companies that can assist with spreading the payment out over multiple months with a minimal interest charge.

One final note on the back surgery cost with insurance and without insurance, it is important to understand if your provider will be providing this service inpatient or outpatient. Inpatient means that the service will be provided within a hospital and outpatient typically means the service will be provided and in an ambulatory surgery center. With both settings, it is important to understand if the charges that you will receive will be bundled - meaning they are all lumped into one billed charge or if you will receive multiple bills from multiple different providers. What this means is typically a non-bundled charge you will receive a bill for the facility, the surgeon, the anesthesiologist, and other providers that are taking part in the care you receive. Whereas with a bundled charge you only receive one billed charge for your procedure.

At AOMSI diagnostics, we provide the most accurate spinal imaging available in the healthcare marketplace.  This imaging has been proven in peer-reviewed medical journals to be the most accurate, reliable, and specific spinal imaging when compared to traditional spinal imaging modalities.  Often times we are able to expedite pre-authorizations for surgery or even overturn denials for spinal surgery after the VMA study is presented to insurance.

Contact us today to see if AOMSI diagnostics is right for you!