Exorbitant Charges Billed by Surgeon and Assistant Surgeon for Spine Surgery
In the U.S., back pain is one of the most common reasons people seek medical care and treatment. There are multiple treatment options for back pain and spine conditions including medications, physical therapy, interventional pain management, surgery, less invasive options, and others. These various healthcare services may be performed in a physician office location while others may be performed in an ambulatory surgery center, hospital outpatient surgery department or inpatient hospital operating room.
The cost of spine surgery varies significantly depending on the diagnosis and type of surgery performed. Out-of-pocket cost(s) will depend on the actual procedure(s) performed, physician charges, facility charges, other medical fees, geographic location, and if you have insurance – what the plan covers and reimburses.
Exorbitant Charges and ClaimDOC Reference Based Pricing
In this Audit Spotlight, we focus on exorbitant surgeon and assistant surgeon charges as it relates to spine surgery performed at a hospital located in New Jersey. The breakdown of physician, practitioner and hospital charges as well as ClaimDOC pricing on three claims is outlined below. And, based on the hospital’s itemized bill, total surgery time for the spine surgery was 2.5 hours.
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The Takeaway
Charges billed by healthcare providers vary greatly. Let’s ask the question: do providers truly know what it costs to perform surgery? Or is it more that charges are set using a combination of guesswork and a canny assessment of market opportunity?
Whenever patients have the option, use price-lookup tools, get clear estimates of charges prior to services from the provider, and consider alternatives regarding where to have procedures performed. Some providers are willing to negotiate the cost of treatment.
The improper reporting of services, coding/billing errors and egregious charges can complicate matters for members to understand their healthcare bills and payments, impact the collection of patient balances, build a reputation of providers charging high fees, create burdens for patients having no insurance and a host of others.
When an individual receives a bill for healthcare services appearing questionable/inappropriate, an inquiry to the provider and/or health plan should be made to obtain an explanation of the service(s), corresponding charges and reimbursement. Prices in heath care are not fixed and can be negotiated; they can be discussed and contested.
Our goal at ClaimDOC is to use benchmark charges and costs nationally to negotiate fair and ethical payments. Our high-quality and expert review of claims identifies and prevents improper medical claim payments and maximizes long-term cost savings opportunities. Employers turn to us seeking to establish fair reimbursement rates for their plans allowing them to save money and provide richer benefits to their employees. A win-win for everyone.
Background
ClaimDOC’s comprehensive line-by-line review of claims uncovers errors that basic claim repricing and auto-adjudication does not catch, leading to greater savings for health plans and its plan members. Our audit team analyzes all types of healthcare claims for a variety of potential concerns including excessive usual and customary charges, duplication of claims, incorrect coding, unbundling of services and many others. Our claims review is not intended to impact care decisions or medical practice.