IS IT WORTH GOING OUT OF NETWORK FOR SPINAL SURGERY? [2023 UPDATE]

Your doctor just told you that you’re going to need spinal surgery. Ideas, concerns and questions immediately flood your mind as you think of everything that’s about to change.

You may need to take time off from work, even though deadlines are piling up. You may worry that you will need to shell out a lot of money. You wonder if you will have to stop exerting yourself until you recover, which may mean hitting pause on doing some of the things that you love, and more.

But perhaps most of all, you have a lot of questions about how you’re going to pay for this procedure. The pricing around surgery of any kind can feel ambiguous and unclear as can what your insurance provider is actually going to cover. This can leave many patients with questions like: What procedure will my insurance cover? What’s available to me in-network?

Are the doctors in my network really the best-equipped to perform my surgery?

These pressing questions need clear answers, particularly when they involve spinal surgery. Your spine is integral to your health and mobility. It’s also delicate and complex.

You’re going to want to make sure that you pick the right surgeon for you.

As a patient, you need to be well-informed and clear on all aspects of your surgery, including which surgeons you can trust and how much you are willing to pay for your procedure. In terms of your health insurance, you will need to decide a number of things:

• Is going in-network for surgery the best option for your spinal condition?

• Would out-of-network surgery actually be better?

• Are you willing to pay more for better surgery options that are out-of-network?

We’ll explore answers to these questions and more in this blog post. 

IS TRAVELING OUTSIDE OF YOUR GEOGRAPHICAL AREA FOR SPINE SURGERY WORTH IT?

In a nutshell, yes. Believe it or not, many senior spine surgeons do not utilize the latest technological advances like robotics, endoscopy, artificial discs or other minimally invasive technologies.

One reason is that surgeons can get set in their ways. They believe in the technology that they have used over the years and are hesitant to incorporate new technologies. Moreover, new techniques often require training which could slow them down and time is money.

Also, some new technologies are simply not available everywhere, especially in more rural areas. New technologies may not even be available at large hospitals in major cities. Many large hospitals are run by systems that impose restrictions on technologies their employed surgeons can use. This is often due to costs. Therefore even big hospitals — like those associated with universities — may not adopt new technologies first.

The good news is that the availability of remote or video medical visits now makes consulting an out-of-area surgeon easier than ever before. So if options are limited among your local providers, you may consider looking elsewhere.

WHAT IS THE DIFFERENCE BETWEEN OUT-OF-NETWORK VS. IN-NETWORK PROVIDERS?

Health insurance plans can cover medical expenses from a variety of healthcare providers, but not all.

The healthcare providers covered by your insurance plan are “in-network” providers; those who aren’t covered are “out-of-network” providers. The determination between a physician that is in-network and out-of-network is typically based on the location of the patient; not necessarily physicians’ skill.

For physicians that are in-network, your insurance provider will typically cover the entire cost of your surgery after you reach your deductible (the amount of money that you are responsible to pay).

In case of an emergency, most health insurance providers will cover out-of-network physicians —and it’s usually the only time they will do so.

Out-of-network providers, on the other hand, are typically physicians that are located outside the boundaries of your local insurance. While insurance will often still cover a portion of the fees incurred when visiting a doctor that is out-of-network, the cost to the patient is usually higher.

In preparing for surgery and choosing your surgeon, it’s also important to be cognizant of the fact that the professionals involved in your surgery might not all be covered under your insurance plan. Just because one of them has a contract with your healthcare provider doesn’t mean that all of them do.

That being the case, there are legitimate reasons to go out-of-network, especially when it means finding a surgeon who is best-equipped to care for your specific needs.

When considering going out of network for surgery, there are some things that you should keep in mind as you’re researching:

• Avoid Surgeons with Alternative or ‘Miraculous’ Tools and Methods

• Look for Surgeons with Certified Medicinal Practices

• Choose a Surgeon Who Specializes in Neurosurgery

• Beware of Out-of-Network Spine Surgeons Who Only Accept Direct Full Payments

1. AVOID SURGEONS WITH ALTERNATIVE OR ‘MIRACULOUS’ TOOLS AND METHODS

A legitimate and perfectly normal reason to choose someone out-of-network is that you trust them in particular and know their abilities. However, choosing a surgeon because they use a unique, non-standard tool or they promise miraculous cures could set you up for serious financial or physical trouble.

Surgeons and medical centers, like the now-defunct Laser Spine Institute, that promise miracle cures using newfangled devices or procedures are usually exploiting their patients’ fears of traditional medical technologies or their desperation for a medical solution of any kind.

Many of these alternative spinal surgeries are not only untested but are also considered experimental by insurance companies. That means most insurance companies won’t cover the costs associated with them at all.

And since spine surgeries can cost anywhere from $4,000 to $90,000, patients can be overwhelmed with a huge financial burden. It’s even worse if they find out only after receiving a bill that insurance won’t cover any part of their expensive surgery.

For example, the Laser Spine Institute would offer surgeries that cost $30,000 — double the amount Aetna would cover. Cigna, by contrast, wouldn’t cover the laser portion of the surgery in any way whatsoever, leaving patients to foot the bill.

These scams are even more common outside of the United States, where there is less regulation.

As many as 1.4 million Americans sought health care outside of the U.S. in 2017. Some patients travel to Mexico or Thailand for non-traditional medicine that promises to restore their mobility after being paralyzed, betting on miracle cures.

This isn’t limited, of course, to surgery. Patients even travel to Mexican clinics purporting to have cures for cancer. Some of the treatment methods offered aren’t grounded in science at all and can include guinea pig blood transfusions and zapping patients with electrical currents. Nevertheless, late-term cancer patients swarm to these clinics, desperate for a cure.

A good rule of thumb when considering a spine surgeon is to remember that if something seems too good to be true, it almost always is — and this is particularly true in the medical and scientific world. Seeking unregulated medical treatment could also set you up for a lifetime of expensive remedial care if it goes wrong.

Unfortunately, many patients don’t realize they’re being swindled until it’s too late.

Miracle cures or panaceas have occurred again and again throughout history. The United States has a long, colorful history of “quack” or non-standard medicine that was either useless or actively harmful: snake oil peddled by a cowboy across the country, heroin as a “non-addictive” substitute for morphine, cocaine as stimulant and pain reliever, and ice pick lobotomies.

Non-traditional “medical miracles” treatments like these gained a lot of momentum and public approval, but they didn’t get medical treatment right. Our modern system of regulations and credentials serves patients by keeping them safe from practices that have not been rigorously researched and tested.

“DID YOU KNOW?
As many as 1.4 million Americans sought health care outside of the U.S. in 2017?”

2. LOOK FOR SURGEONS WITH CERTIFIED MEDICINAL PRACTICES

Spinal surgery needs to be executed with precision, using scientifically proven methods and tools. If your surgery goes wrong, you could experience severe pain, lose mobility or suffer fatal consequences. Going out of network to a trusted surgeon who uses well-tested, scientifically-proven equipment is fundamentally safer than hiring a surgeon who uses a miracle tool or treatment.

Due to the nature of surgery in particular, tools figure prominently in the procedure. They’re also a useful way to gauge whether a given surgeon is using medically legitimate methods or not.

For instance, “miracle tools” are a reliable red flag because the American medical system is simply not built to support limited distribution or sale of truly revolutionary medical implements. There is no well-tested tool that is also only available to individual surgeons or centers.

The reason is simple: It would be financially disastrous for medical technology companies to only sell to one place or practitioner after making it through the testing and approval process. Any surgical tool used in an accredited medical center needs to first be approved by the U.S. Food and Drug Administration (FDA) for safety and efficacy. This process takes between three to seven years and costs an average of $31 million.

Any company that commits to making a safe and useful FDA-approved product will want to maximize their return on investment by selling the technology to as many hospitals as they can. Thus, selling to hospitals will generate more revenue than selling selectively to individual surgeons or practices, and revenue is critical after expending millions on the approval process.

In some cases, experimental trials occur at well-established medical centers. You will still get the best quality of care here, and the trials are clearly presented as just that — trials, not miracles. But unless you have a very specific ailment and are willing to take part in experimental trials, regular hospital treatment is likely to work best for you.

“DID YOU KNOW?
Any surgical tool used in an accredited medical center must be approved by the FDA for safety and efficacy? This process takes between three to seven years and costs an average of $31 million.”

3. CHOOSE A SURGEON WHO SPECIALIZES IN NEUROSURGERY

In general, you can’t go wrong with choosing a reputable surgeon, whether in-network or out-of-network, who will offer you the best therapeutic results. And it’s always a good idea to avoid surgeons or surgical centers that promise cures that seem non-standard or simply too good to be true.

But not all surgeons are created equal.

Surgeons with different specialties will often receive vastly different training, education and experience; they may have entirely different kinds of expertise, even if they perform surgeries on the same parts of the body to treat the same conditions!

This is especially true when it comes to spine surgery. Both orthopedic surgeons and neurosurgeons are licensed to perform many of the most common and important spinal surgeries. But these two different kinds of surgeons cannot provide the same kind of expertise and care.

While there may be plenty of reasons to see an orthopedic surgeon for certain procedures, only neurosurgeons truly specialize in handling the complex nervous system of the spine. 

Here's a helpful graphic that points out some of the key differences between neurosurgeons and orthopedic spine surgeons:

So when considering out-of-network or in-network surgeons for your spine surgery, do not forget to choose a surgeon who specializes in the care you need. For most forms of spinal surgery, that means picking a neurosurgeon.

To do so, you’ll want to draft a list of prospective surgeons you can inquire with. Once you’ve narrowed your list down, the next step is navigating surgery cost and the extent to which it is or is not covered by your insurance policy.

“DID YOU KNOW?
Neurosurgeons are specifically trained to treat issues dealing with the nervous system. This includes the spine, spinal cord and the brain. ”

4. BEWARE OF OUT OF NETWORK SPINE SURGEONS WHO ONLY ACCEPT DIRECT FULL PAYMENTS FROM THE PATIENT

Spine surgeons in the United States perform more spine surgeries, especially fusions, and there are more spine surgeons here than in the rest of the developed nations combined.

Therefore, there is simply no reason at this time to choose a spine surgeon who expects upfront direct payment from the patient and expects the patient to collect from the insurance company.

There are reasonable out-of-network spine surgeons who will work directly with your insurance company to negotiate a reasonable fee.

There are many senior spine surgeons with vast clinical experience who choose to stay out-of-network with certain insurance companies due to the unfair practices that they force on in-network surgeons. Staying out-of-network is the only leverage these surgeons have of being treated more fairly by these insurance companies.

HOW MUCH DOES OUT-OF-NETWORK SPINE SURGERY REALLY COST?

Most people would agree that healthcare in the United States is expensive.

Many Americans are afraid of losing their health insurance because they dread the cost of obtaining healthcare.

This is especially the case when you consider the above-average costs of complicated surgeries. The average cost of a hip replacement surgery is $40,364. The average cost of a heart bypass is $123,000. And without insurance, spinal surgeries can cost tens of thousands of dollars. Few can afford important surgeries without the help of an insurance provider.

As such, some may assume that going out-of-network for surgery is simply the wrong decision. Why pay more, and perhaps too much, for surgery you can surely find an in-network surgeon for?

But the truth is that out-of-network surgeries are not quite as expensive as people might believe.

In fact, insurance often covers significant portions of out-of-network surgeries, and while the precise amount of coverage will vary from plan to plan, at least some amount of coverage is virtually guaranteed.

What’s more, cost isn’t the only reason to choose a surgeon. It often isn’t even the most important. Finding a doctor that is best able to treat your spinal condition in the safest, least-invasive way is vitally important.

Successful surgeries that leave a lasting, positive impact come from good relationships between surgeons and patients. Choosing a surgeon you trust and who has the recognized expertise to deliver the care you need can be a perfectly valid reason to go out-of-network for surgery.

The key is to know the costs you are willing to assume to find a surgeon you want and the coverage provided by your insurance provider. Though the last point may be easier said than done, given how confusing insurance often is.

INSURANCE CONFUSION

More than half of Americans report feeling “completely lost” when trying to understand their medical insurance. In a poll about basic healthcare terms, 61% of Americans confused the definition of premiums with that of deductibles.

That’s a striking disconnect.

More Americans than ever have health insurance, but over half of those insured feel lost trying to understand what it provides them, and how. This leads to a number of problems.

Confusion about insurance plans and insurance terms can keep many people from getting the best care possible at an affordable rate. As a result, Americans estimate they unintentionally waste more than $110 each month on health coverage.

Proper healthcare at an appropriate price is particularly important in surgery because surgeries can permanently alter a patient’s life. And with 48 million outpatient surgeries being performed every year, understanding insurance coverage is likely to be relevant to your health.

When deciding between out-of-network surgeons or in-network surgeons, knowing your insurance plan can make the difference between elevated rates or paying close to in-network rates. Different kinds of insurance plans will offer different levels of coverage, with HMOs and EPOs offering less coverage than PPOs and POS plans.

Getting clarity about your own insurance is a great first step to deciding on whether out-of-network surgeries or healthcare.

Look up your insurance information, talk to your insurance provider and feel free to even talk to your doctor or surgeon about your insurance! It’s crucial to get the information you need to make the decision that’s right for you.

“DID YOU KNOW?
More than 50% of Americans report feeling “completely lost” when trying to understand their medical insurance.”

CONCLUSION

Getting spinal surgery is a serious decision. You have one spine for life. Getting the right surgery for you is invaluable — as is choosing the right surgeon and preparing financially for the procedure.

Choose a surgeon you can trust within a financial arrangement that is feasible for you.

For some, that might mean opting to use a surgeon outside of your health insurance network. For others, it means choosing a surgeon from a list of in-network providers.

Regardless of your financial considerations, your best surgical care will be at a medical center that operates using safe, proven tools and methods. Miracle cures are a needless risk, both financially and physically.

If you choose to go out-of-network to get spinal surgery, make sure it is worth your time, money and benefits your health.