HOW MUCH DOES BACK SURGERY COST WITH INSURANCE

January 7, 2021 Nicholas Lancaster

How Much Does Back Surgery Cost with Insurance

Health insurance can be your best friend or your worst nightmare. When it comes to considering back surgery it is very important to understand your options with insurance. A back-surgery cost with insurance can be very complex if you are unfamiliar with the ins and outs of spine care and the basics of how insurance works.

To start, before considering any type of surgery it is important to make sure that all conservative treatment options have been exhausted. Conservative treatment includes but is not limited to physical therapy, chiropractic care, acupuncture, and pain management. Not only is exhausting conservative therapy in the best interest of you the patient, but it also is one of the major components that insurance looks at when considering approval of any type of spine surgery. Most insurance companies require at least six months of conservative therapy before considering approval for spine surgery. As with anything, there are exceptions to this rule for example if you have an emergent condition that needs spine surgery immediately.

Once you have checked off the box of exhausting conservative therapy and you have been recommended surgery from your provider the next step is to obtain preauthorization for your surgical procedure. Your doctor's office should obtain this preauthorization for you however if they do not it is a good idea to call your insurance company yourself and obtain their steps for preauthorization approval. On the off chance that your preauthorization is denied we at AOMSI diagnostics have seen success with overturning Fusion denials when a patient undergoes a VMA scan to accurately measure spinal instability. If your surgery has been denied preauthorization please contact our office to speak with a representative and determine if a VMA scan would be appropriate for your case.

Once you have preauthorization approved from your insurance company, the next step is to fully understand three essential parts of your insurance policy: deductible, out of pocket maximum, and co-insurance.

Deductible

Your insurance deductible is defined as the amount you are responsible to pay out of pocket before your insurance will pick up payment for your medical services. Each plan will have an in-network deductible and an out-of-network deductible.

· An In-network provider means that the provider has agreed to a contract with your insurance company.

· An out-of-network provider means that the provider has not agreed to a contract with your insurance company (Just because your provider is out-of-network does not bear any indication of the quality of the medical provider).

For some policies you will not have out of network benefits, you will only have in-network benefit. This means that if you see a provider who is out of network with your insurance policy you will be responsible for the cash pay rate for any medical services that are rendered.

For a plan that has in-network and out of network benefits the deductible is for the entire calendar year. As you pay for any out-of-pocket cost for in-network or out of network medical care the payments you make will go toward your deductible for that calendar year. When determining the cost of spine surgery with insurance it is important to know if your spine care provider is in-network with your insurance or out of network.

Once you identify if they are in-network or out of network with your plan, you can call your insurance company or verify online how much of your deductible you have met for the calendar year. If you plan to have surgery towards the end of the calendar year typically you will have met more of your deductible for your insurance plan. As stated above, once you meet your deductible your insurance will begin paying the set percentage as determined by your policy.

For example:

In-Network Deductible - $5,000 Plan pays 80%

Out-of-Network Deductible - $8,000 Plan pays 60%

In the above example, once the patient pays $5,000 out of pocket for medical services within the calendar year – the insurance plan will pay 80% of medical charges. The remaining 20% will be the patient’s responsibility to pay.

Out-of-Pocket Maximum

The Out-of-Pocket Maximum is the maximum amount of payment you will be responsible for in one year. For example, if your Out-of-Pocket maximum for In-network services is $7,000. $7,000 is the maximum amount you will be required to pay for In-network medical services. Anything above the $7,000 will be paid at 100%, i.e., you will not be responsible for payment. Your Out-of-Pocket Maximum is the total you have paid for medical services including the deductible amount.

Let’s say you had $20,000 of In-network billed medical services in one year. Using the same plan as stated above you would be responsible to pay $5,000 to meet your deductible. Once your deductible has been met, your plan will pay 80% of the charges. You will be responsible for the remaining 20% until your $7,000 Out-of-Pocket Maximum has been met.

See below:

Total Charges: $20,000.00

Deductible: $5,000.00 (patient responsibility)

Remaining Total Charges: $20,000.00 - $5,000.00 (Deductible) = $15,000.00

$15,000.00 x 80% (Insurance pays b/c deductible met) = $12,000.00

$15,000.00 x 20% (patient responsibility) = $3,000.00

OOP Maximum: $5,000 (deductible) + $3,000 (patient responsibility) = $8,000

$8,000 - $7,000 (OOP Max) = $1,000 (Insurance pays @ 100%)

Co-Insurance: $2,000.00 (patient responsibility)

For $20,000 of In-network billed medical services in one year using the above plan details a patient is only required to pay a total of $7,000 (total OOP maximum).

Co-insurance

The final piece of the equation when it comes to understanding cost with insurance is Co-insurance. Co-insurance is the difference between your deductible and the patient’s out of pocket maximum. Using the example above: $7,000 (OOP Max) - $5,000 (Deductible) = $2,000 (Co-insurance). Co-insurance is defined as the total amount the patient is responsible for paying WITH insurance before the insurance plan will pay at 100% for billed medical services. This is a very important number to understand as most patients will look at the deductible for the year and assume that is the total amount they will be responsible for medical services. This is not the case; the patient will be responsible for their Deductible + Co-insurance = OOP Maximum.

When it comes to back surgery and determining the cost with insurance it is important to consider all of the following in order to determine the total out of pocket cost for a patient.

· Is the Medical Provider In-network or Out-of-Network?

· Is pre-authorization required by my insurance plan for this procedure?

· What is the exact amount that will be billed for the back surgery by the medical provider?

· What is the patient’s applicable (in-network/out-of-network) deductible?

· What is the patient’s applicable (in-network/out-of-network) OOP maximum?

· What is the patient’s potential Co-insurance responsibility (OOP maximum – Deductible)?

Once the above items are defined, the total cost for back surgery can simply be calculated by adding the following:

Amount left on the patient deductible for the year + Co-insurance (OOP Maximum – Deductible) = Total Out of Pocket Cost for a Back Surgery.

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.