Abstract Title: Evaluating Insurance Reimbursement for Kyphoplasty in an Outpatient Setting: A Comparative Analysis
Background: Kyphoplasty, a minimally invasive procedure for treating painful osteoporotic vertebral compression fractures (VCFs), offers immediate pain relief and restores premorbid levels of daily activities. This procedure can often be performed safely and effectively in an outpatient clinic, significantly reducing costs compared to a hospital setting.
Purpose/Objectives: This study aims to analyze the reimbursement rates and payment times of various insurance providers for kyphoplasty procedures performed in a pain clinic office setting.
Methods: The study compared costs and payment times from different insurers. In a hospital setting, kyphoplasty costs range from $10,000 to $20,000. In our clinic, the procedure takes approximately 30 minutes, with 45 minutes for recovery, costing around $2,000 for the kyphoplasty kit, up to $150 for CRNA time, and less than $100 for additional equipment.
Results: Medicaid is the fastest payer, with an average payment time of 14 days. BCBS of Alabama, covering over 90% of private insurance in Alabama, is the slowest payer, taking 366 days, but it provides the highest reimbursement at $7,200. UnitedHealth Group, despite its $22 billion profit in 2023, offers a lower reimbursement of $4,300, with a payment time of 35 days. Cigna is the second lowest payer, with a reimbursement of $4,800 and a lengthy payment time exceeding 180 days, making it the least favorable insurer for providers when considering both reimbursement and payment time.
Conclusions/Implications for future research and/or clinical care: Kyphoplasty in a private clinic by an experienced pain management specialist is efficient and cost-effective. However, reimbursement processes need to be streamlined, with a preference for Medicaid due to its prompt payments. BCBS should expedite its payment process, and providers might consider avoiding UnitedHealth Group and Cigna due to their lower reimbursements and delayed payments.
References:
Mehio, A.K., Lerner, J.H., Engelhart, L.M., Kozma, C.M., Slaton, T.L., Edwards, N.C., & Lawlere, G.J. (2011). Comparative Hospital Economics and Patient Presentation: Vertebroplasty and Kyphoplasty for the Treatment of Vertebral Compression Fracture. AJNR Am J Neuroradiol., 32(7), 1290–1294. doi:10.3174/ajnr.A2502
Japsen, B. (2024). UnitedHealth Group Profits Hit $22 Billion In 2023. Forbes. Retrieved from Forbes.
U.S. Department of Justice. (n.d.). 32 Hospitals Pay US More Than $28 Million to Resolve False Claims Act Allegations Related to Kyphoplasty. Retrieved from Justice.gov.
