Commercial Payors More Likely to Reimburse Unlisted Hip Arthroscopy Procedures Compared With Managed Care but With Similar Overall Dollar Amount.

Abstract

Purpose: To compare the reimbursement practices of public managed care (MC) insurance versus private commercial insurance (COM) for hip arthroscopy using the current procedural terminology (CPT) code 29999.

Methods: The CPT codes and corresponding reimbursements of hip arthroscopies that employed code 29999 performed from January 2020 to December 2024 in a multihospital health system were analyzed. Patients' insurance carriers were identified and grouped into either MC or COM. MC consisted of Medicaid and Medicare. The outcomes analyzed were as follows: whether any reimbursement was obtained, total dollar amount paid, percentage of the billing that was reimbursed, and the percentage of CPT 29999 charge that was reimbursed.

Results: One hundred thirty-seven hip arthroscopies met the inclusion criteria. COM fulfilled at least part of the reimbursement (i.e., not completely deny the entire claim) in 100% of cases, whereas MC provided at least some payment in 94.1% of claims (P = .02). However, there was no significant difference in the total dollar amount ($3191.18 vs $3563.02; P = .109) or percentage of the total charge (20.0% vs 21.7%; P = .220) reimbursed by MC relative to COM, respectively. Similarly, there was no significant difference in the percentage of CPT code 29999 reimbursed between MC and COM (25.0 vs 21.2%; P = .185).

Conclusions: COM was less likely to completely deny a claim relative to MC and reimbursed approximately 10% higher than MC. However, there was no significant difference between payors in the percentage of the billing that was reimbursed or the percentage of reimbursement specifically for CPT code 29999. Regardless of insurance type, there is a low percentage of reimbursement for unlisted hip arthroscopy procedures.

Clinical relevance: As hip arthroscopy becomes more common, it is important to understand reimbursement patterns to ensure patients receive appropriate care and surgeons are compensated. This study provides insights that help surgeons navigate these dynamics and deliver high-quality care, regardless of a patient's insurance provider.