Commercial & Medicare Insurance Plans & Pricing

Commercial Insurance Payor Rates

Click here to see a list of our current contracted carriers. If you do not see your insurance company listed, please call and we can confirm.

Commercial insurance companies do not allow facilities to share their contracted rates with the public. We at OSCC believe this creates a challenge for the consumer who is researching facilities and trying to determine out-of-pocket costs. In an attempt to assist our patients, and potential patients, we have included on this webpage a list of our most common procedures along with our charges, estimated contracted rates based on our current insurance contracts, and the federally regulated Medicare rates.  Please click here to skip ahead to the prices or continue reading to learn more about specific terms and pricing methodology.

PLEASE NOTE:

“CPT” represents the procedure code performed on a particular case. When a doctor schedules a surgical case he will submit a scheduling form that includes the predicted CPT codes that are going to be performed. We then use these codes to estimate your out-of-pocket expense. These codes are only estimates and may vary slightly upon completion of a surgical case. Our physicians have enough experience that they can accurately predict the procedures the vast majority of the time. However, even if they are inaccurate, most codes are similarly priced since the code is simply there to best describe the procedure performed. Furthermore, if additional codes are added, they tend to have minimum impact due to the fact that multiple codes are discounted even further. For example, a commercial insurance company may pay 100% of the contracted rate for the first code, 50% for the second code, and 25% for the third code. If the third code is added during surgery and it is contractually reimbursed at $750, it would be discounted to $187 per the 25% rule. If the patient has a 30% co-insurance, then the patient’s share of that third code is $56. While estimates do sometimes vary from the final amount, we promise to do our best to provide you with our most accurate estimate based on the provided information.

“CHARGES” represent the amount that is submitted to the insurance company. This amount will always be a large number since all contracts, worker’s comp claims, personal injury claims, jury settlements, and self pay claims are a negotiated discount from this “charge” amount. This “charge” amount means very little to the patient so long as he or she has a contracted or agreed upon rate. The patients who are most often affected, and most often read about in the news, are those who have no insurance. This is why we became the first ambulatory surgery center in Florida to share our discounted self pay prices online so that patients with no insurance can be assured that they will not be left with a surprise bill.

“MEDICARE RATE” represents the price set by the Federal government for patients who have Medicare insurance plan. Every region is slightly different. For example, Clearwater facilities receive a discounted rate of 95.38% of the national rate. The patient’s out of pocket responsibility, if they do not have a secondary insurance plan, is always 20% of the Medicare rate. Currently, the reimbursement rate for ambulatory surgery centers is about 55% of what the hospital is paid for performing the exact same procedure. This means that Medicare patients will pay out of pocket about twice as much at the hospital simply because it is a different building. Medicare is considered to be the lowest threshold for which we can be paid. The reimbursement rate does not reimburse for surgical implants separately as do most commercial payors. Because Medicare is financed by the tax payer, the Federal government believes that surgery centers should not make a profit performing these procedures. Medicare pays 100% for the first submitted CPT code and 50% for each additional code for up to five(5) codes.

“COMMERICAL RATE” represents an estimated contracted rate through one of our commercial insurance companies. Until you are scheduled, or reasonably expect to be scheduled, we are contractually forbidden from sharing our commercial rates openly with the public. If you expect to be scheduled for surgery and need to know your out-of-pocket costs, please do not hesitate to call and provide us with your doctor’s name, insurance provider, and the CPT codes provided by your surgeon. We can then provide you with estimates based on your specific plan and surgical needs. When an insurance company pays for multiple procedures, they do so on a discounted basis where the first procedure is paid at 100% and the second procedure is paid at 50% with discounts for any additional procedure varying based on the insurance provider. Unlike Medicare, most commercial insurance providers pay for implant costs separately and apply the costs to your deductible and/or co-insurance. At OSCC, we will call you and provide your out-of-pocket estimate as soon as your physician schedules a surgery for you at our facility.

“IMPLANTS” are pieces of hardware that are put in the body during surgery and are reasonably expected to remain in the body. Implants include such things as screws, plates, anchors, and grafts. Implants do not include temporary items such suture, specialized tools, drill bits, monitoring equipment, or staples. The Federal Government has estimated the implant costs and built them into the Medicare reimbursement price. However, they have often been wrong in their estimate and if a case costs more to perform than it is reimbursed, we will often request that the procedure be performed in the hospital where reimbursement is twice the amount we receive. Without the support of legislation like the ASC Quality & Access Act the problem of being reimbursed too little to cover expenses will continue to expand. Commercial insurance plans vary on how they handle the reimbursement of implant costs. Blue Cross Blue Shield uses a company called IPG that pays for the implant on behalf of the surgery facility. IPG will then either collect payment from BCBS or will collect payment from the patient based on the patient’s specific insurance plan (i.e. If the patient has a 20% co-insurance, then IPG will send a bill to the patient for 20% of the implant costs.). Other commercial insurance companies typically add the costs of the implant to the cost of care, apply it to the patient’s deductible and/or co-insurance, and then will seek payment from the patient. Implant costs vary based upon the patient’s specific needs. Extensive damage may require additional plates and screws. Your specific needs can be estimated by your surgeon but the final implant usage will depend on the work completed during surgery.

THE RATES BELOW ARE ESTIMATES AND DO NOT REFLECT YOUR SPECIFIC SURGICAL NEEDS. THESE RATES ARE FOR INFORMATIONAL PURPOSES ONLY TO ALLOW YOU TO BETTER UNDERSTAND THE SURGICAL REIMBURSEMENT METHODOLOGY FOR OUR AMBULATORY SURGERY CENTER.

Description CPT Full Facility Charge w/ NO Discount Estimated Commercial Insurance Reimbursement Estimated Implant Costs Medicare Reimbursement
REMOVAL OF IMPLANT; DEEP 20680 10,892 1,127 N/A 953
ARTHRODESIS,ANTERIOR INTERBODY, INCLUDING DISC SPACE PREPARATION, DISCECTOMY 22551 23,573 3,053 $5,349 7,481
REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (i.e, ROTATOR CUFF) OPEN REPAIR 23410 22,500 1,422 $350 – $1,800 1967
BICEP REPAIR 23430 8,413 1,766 $435 1,967
REPAIR OF RUPTURED TENDON 24342 9,150 1,766 $180 – $400 1,967
INCISION, EXTENSOR TENDON SHEATH, WRIST 25000 6,925 1,068 N/A 868
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID 25605 15,085 647 N/A 372
ORIF DISTAL RADIUS 25607 8,188 2,190 $1,200 – $3,000 3,948
TENDON SHEATH INCISION (FOR EXAMPLE: TRIGGER FINGER) 26055 8,150 820 N/A 642
EXCISION OF LESION OF TENDON SHEATH OR JOINT CAPSULE (i.e., CYST, MUCOUS CYST, OR GANGLION), HAND OR FINGER 26160 6,245 820 N/A 642
ORIF METACARPAL FRACTURE 26615 10,268 1,592 $20 – $500 2,210
TREATMENT OF FINGER FRACTURE 26735 9,975 1,184 $50- $1,200 1,068
AMPUTATION, FINGER OR THUMB 26951 2,894 715 N/A 642
ACHILLES REPAIR 27650 7,675 1,592 $170 – $2,000 1,967
PART REMOVAL OF METATARSAL 28110 4,400 1,095 N/A 911
PART REMOVAL OF ANKLE/HEEL 28120 12,845 1,189 N/A 911
CORRECTION OF TOE JOINT DEFORMITY (HAMMERTOE) 28285 3,663 1,095 $20 – $950 911
CORRECTION BUNION 28296 3,663 1,076 $20 – $1,100 1,399
ARTHROSCOPY, SHOULDER, SURGICAL; DEBRIDEMENT, LIMITED 29822 13,800 1,942 N/A 1,125
SHOULDER, SURGICAL; DEBRIDEMENT, EXTENSIVE 29823 15,110 2,549 N/A 2,271
SURGICAL; DISTAL CLAVICULECTOMY INCLUDING DISTAL ARTICULAR SURFACE (MUMFORD PROCEDURE) 29824 12,458 2,913 N/A 2,271
ARTHROSCOPY, SHOULDER, SURGICAL; WITH ROTATOR CUFF REPAIR 29827 21,960 2,549 $180 – $2,000 2,271
ARTHROSCOPY, KNEE, SURGICAL; WITH LATERAL RELEASE 29873 10,180 1,942 N/A 1,125
ARTHROSCOPY, KNEE, SURGICAL; SYNOVECTOMY, LIMITED (EG, PLICA OR SHELF RESECTION) (SEPARATE PROCEDURE) 29875 11,850 1,980 N/A 1,125
ARTHROSCOPY, KNEE, SURGICAL; SYNOVECTOMY, MAJOR, TWO OR MORE COMPARTMENTS (i.e., MEDIAL OR LATERAL) 29876 10,173 1,942 N/A 1,125
DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY) 29877 12,322 1,942 N/A 1,125
ARTHROSCOPY, KNEE, SURGICAL; ABRASION ARTHROPLASTY (INCLUDES CHONDROPLASTY WHERE NECESSARY) OR MULTIPLE DRILLING OR MICROFRACTURE 29879 13,755 1,942 N/A 1,125
ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL AND LATERAL, INCLUDING ANY MENISCAL SHAVING) 29880 14,800 1,942 N/A 1,125
ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL OR LATERAL, INCLUDING ANY MENISCAL SHAVING) 29881 14,864 1,942 N/A 1,125
ARTHROSCOPICALLY AIDED ANTERIOR CRUCIATE LIGAMENT REPAIR/AUGMENTATION OR RECONSTRUCTION 29888 23,524 2,732 ” Autograft $300 – $800
Allograft $2,050 – $3,580 “
3,305
ANKLE ARTHROSCOPE 29892 13,645 2,255 N/A 1,967
REPAIR OF FIBROUS TISSUE OF FOOT (PLANTAR FASCIOTOMY) 29893 3,150 1,777 N/A 911
ANKLE ARTHROSCOPE 29894 12,280 1,980 N/A 1,125
MICRODISECTOMY- LAMINOTOMY, WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC; ONE INTERSPACE, LUMBAR (INCLUDING OPEN OR ENDOSCOPICALLY-ASSISTED APPROACH) 63030 15,590 3,192 N/A 2,150
LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], SINGLE VERTEBRAL SEGMENT; LUMBAR 63047 18,750 3,192 N/A 2,150
INJECTION, ANESTHETIC AGENT; BRACHIAL PLEXUS, SINGLE LEVEL 64415 3,905 376 N/A 195
INJECTION, ANESTHETIC AGENT; AXILLARY NERVE 64417 3,600 376 N/A 195
INJECTION, ANESTHETIC AGENT; SCIATIC NERVE, SINGLE LEVEL 64445 4,115 318 N/A 76
INJECTION, ANESTHETIC AGENT; FEMORAL NERVE, CONTINUOUS INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT) 64448 7,050 559 N/A 768
INJECTION, ANESTHETIC AGENT AND/OR STEROID, TRANSFORAMINAL EPIDURAL; CERVICAL OR THORACIC, SINGLE LEVEL 64479 6,073 442 N/A 351
(EACH ADDITIONAL LEVEL) INJECTION, ANESTHETIC AGENT AND/OR STEROID, TRANSFORAMINAL EPIDURAL; CERVICAL OR THORACIC 64480 2,928 374 N/A N/A
INJECTION, ANESTHETIC AGENT AND/OR STEROID, TRANSFORAMINAL EPIDURAL; LUMBAR OR SACRAL, SINGLE LEVEL 64483 5,485 442 N/A 351
(EACH ADDITIONAL LEVEL) INJECTION, ANESTHETIC AGENT AND/OR STEROID, TRANSFORAMINAL EPIDURAL; LUMBAR OR SACRAL 64484 2,750 376 N/A N/A
NEUROPLASTY AND/OR TRANSPOSITION; MEDIAN NERVE AT CARPAL TUNNEL 64721 8,644 878 N/A 723