White Paper

Robust Data and Real Experience — Mastering Logic for Implant Reimbursement

Surgical implant reimbursement can be a tricky field to navigate when it comes to analyzing the data. The Paradigm Specialty Networks team aims to add clarity for payers.

White Paper Summary

Surgical implants bring tremendous benefits to patients and are vital to help injured workers regain their health. And while positive patient outcomes are always the top priority, payers must also pay close attention to realistic implant costs based on clean and thorough data.

Did you know that implant charges on average account for almost a quarter of the total surgical bill?

Even more staggering for high acuity cases including multi-level spinal fusion and pain cases, this number can skyrocket to well over 50%. This equates to over $3.2 billion in annual workers’ compensation medical spend, making implants a significant cost driver.

Interpreting an injured worker’s surgical bill can be challenging for many payers. It’s no surprise that implant pricing is complex and can often seem unpredictable. It is influenced by many factors including wholesale cost, state law, surgical practice, and implant design — just to name a few.

In today’s market, standard bill review tools and subjective negotiation tactics are the common approaches to reimbursing implant bills, despite their complexity.

So, how do you determine the fair and accurate price of an implant with so many variables to consider? Our team has mastered this logic.


To see more from Paradigm, please click here.

For almost 30 years, Paradigm has set the standard for outcomes-focused care and for transforming the lives of catastrophically injured workers and their families. Today, we offer an expanded set of innovative solutions that allow us to deliver better health outcomes and a better value for our clients.

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