Back Surgery and its Back Breaking Implant Costs
Back pain comes in at #8 on the Top 10 list of diseases in America, costing over $40 billion annually for treatment costs. A quarter of that amount ($11 billion) is for back surgeries.
Business is flourishing, in part because of what Dr. Richard Deyo of Oregon Health and Science University alarmingly describes as “financial incentives involving both surgeons and hospitals.”
So while one’s back distress is tough enough to endure, the financial costs are the real agony. Here’s why:
Back operations are costly in terms of wasted dollars up-front: Avoidable back procedures waste well over $500 million per year!
The solution here is to be proactive. Yes, some people definitely need surgery. However, statistics show that the vast majority are not needed. A myriad of treatments (massage, anti-inflammatories, heating pads, etc.) are available that bring relief. If, as a last resort, your doctor does suggest a trip to the operating room, it’s still a good idea to get a second opinion.
Even more dollars are squandered during surgery, i.e. the screws are put to us once again. Take this recent back surgery (we have replicated the bill for public consumption) as a case study in dual pain. It appears to be just another complicated procedure within a facility, where the payor is able process this implant-laden claim with a standard network discount.
But let’s—ahem—back up a second. The implants represent a whopping 72% of the total billed charges! Can that be right? Let’s do a little operation of our own to see what’s amiss.
It is common knowledge among payers of Medical and Workers’ Compensation claims that implants are inflated. But by how much? Depending on the state they are administering in, WC claims adjudicators have an edge where law stipulates implant invoices must be supplied. Utilizing ImplantDx, let’s exploit that edge:
So in this case, the statistics show that the implant costs alone on this one procedure were grossly inflated to the tune of nearly half a million dollars! Valuable information in hand, the payor was able to negotiate with the network, resulting in a happier outcome.
THE ENEMY (WITHIN)
Implant device charges are a challenge—you are not alone in your misery. These charges cost payors a fortune, and getting a copy of the invoice from a provider, well… we all know that’s a pain in the neck! But the problems run even deeper.
Assuming you saved the day by fending off the masked villain, Lack of Transparency Man, by obtaining the invoice, other wickedness lurks in the shadows. Looming large is the fact that invoices may not (and often do not) reflect what the provider actually paid! The diabolical truth is that volume-based discounts, rebates and other financial incentives never make their way to the invoice.
It’s easy to play the blame game, accusing others of harm through their unscrupulous tactics and obfuscations. And while it all may be true, we have to start fighting the good fight and do our fair share of push-back . The lack of transparency issues, network restrictions and constraints are hampering your ability to do your job most efficiently and productively. One must realize that information is power, and the risk of not having enough is to be ineffective, and mired in the status quo.
BE YOUR OWN HERO
There is a way to overcome these challenges. Armed with the correct plan language, financial and clinical understanding, implant information (including their efficacy), strong precertification procedures and the right strategies, you might soon see that the real solution to overcoming back pain is using your brain.
Brought to you by
President Advanced Medical Strategies
& The Predict Solution Suite