Is It Worth Going Out of Network for Spinal Surgery?

Your doctor just told you that you’re going to need spinal surgery. Ideas crowd your head 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 feel like you need to shell out a lot of money. You may 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 pressing of all, you will also 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 will my insurance cover? What’s in-network? Are the doctors in my network really the best-equipped to perform my surgery?

Big questions need clear answers, particularly when they involve spinal surgery. Your spine is integral to your life 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 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 like is going in-network for your surgery the best option for your spinal condition? Would out-of-network surgery actually be better? Are you willing to pay more for a better surgery that is out-of-network?

We’ll answer these questions and more in this blog post around what it means to go out-of-network for spine surgery.

First, we’ll start with one of the most financially important distinctions in insurance: “in-network” vs. “out-of-network” care.

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 physician 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 phyisicans — but that is the only time it 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 while visiting a doctor that is out-of-network, the cost to the patient is usually higher.

While 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:

1. Surgeons with alternative or ‘miraculous’ tools and methods aren’t always better

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.

But many of these alternative spinal surgeries are not just untested; they are also considered experimental by insurance companies. That means most insurance companies won’t cover the costs associated with them at all.

That matters because spine surgeries can cost anywhere from $4000-$90,000. Patients can be overwhelmed with a huge financial burden if they find out only after they get a bill that insurance won’t cover any part of their expensive surgery.

To give just one example, the Laser Spine Institute would offer surgeries that cost $30,000 — fully double what Aetna would cover. Cigna, by contrast, wouldn’t cover the laser portion of the surgery in any way whatsoever.

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 travel to Mexican clinics purporting to have cures for cancer. Some of the treatment methods offered are grounded in no 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.

The now-infamous Elizabeth Holmes stands out among contemporary medical “miracle-workers” due to her level of success. Holmes founded Theranos Inc. and tricked over 176,000 consumers into believing in the legitimacy of her finger-prick blood test.

Theranos Inc. was built on the idea that blood tests could be done with an infinitesimal fraction of a typical blood draw. Valued at $9 billion, Theranos Inc. had supporters such as former President Bill Clinton, former Secretary of State Henry Kissinger and billionaire Carlos Slim. At its peak, her company operated 40 centers inside Walgreens stores in the Phoenix Metropolitan Area.

Her blood-testing machines were completely unreliable. But because they would never show error messages and Theranos Inc. employees were instructed to change patient test results, no one realized the fraud for years.

Miracle cures or panaceas recur again and again through history. America 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 America, heroin as a “non-addictive” substitute for morphine, cocaine as stimulant and pain reliever, ice pick lobotomies.

Non-traditional “medical miracles” like these can gain a lot of momentum and public approval, but they can’t get medical treatment right. Our modern system of regulations and credentials in place serves patients by keeping them safe.

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 die. 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 cause 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 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. 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 experiments, 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 Spine Surgery

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 specialities 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. 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.

How much does out-of-network spine surgery really cost?

Most people agree that healthcare is expensive, and most people are afraid of how much it can affect them financially. 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.

Many people think that this means 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, some amount of coverage is virtually guaranteed.

What’s more, cost isn’t the only reason to choose a surgeon. In fact, 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 what both your own financial situation, the costs you are willing to assume to find a surgeon you want, and the coverage provided by your insurance provider. That 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. Nearly every American has healthcare, but over half of those insured feel desperately 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 a rate that works for them. 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.

For 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 out-of-network surgeries or healthcare. Look up your insurance information, talk to your insurance provider, feel free to even talk to your doctor or surgeon about your insurance! You can get the information you need to make the decision that’s right for you; you just have to look for it!

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 and your family. 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 health. Otherwise, you are putting yourself in an unsafe situation both physically and financially.

Is out of network surgery is right for you? We'll help you find out:

  1. Have you had an MRI of your neck or back?
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Atlantic Brain and Spine A graduate of both Yale and Stanford, Dr. Jae Lim is a board-certified spine surgeon who specializes in minimally invasive spine surgery and robotic spine surgery, significantly reducing surgical impact and recovery times. (703) 876-4270
8501 Arlington Blvd. Suite 330
Fairfax
Virgina
22031
United States
Jae Y. Lim Ben L. Nguyen