The cost of an outpatient orthopedic procedure depends on multiple variables beyond the surgeon’s fee, including site of service, implants, staffing and payer requirements.
Outpatient orthopedic cases are expanding rapidly — in 2023, outpatient orthopedic procedure volume was 33 times higher than inpatient.
ASCs generally operate with lower overhead than HOPDs, but reimbursement discrepancies remain a limiting factor. Medicare typically reimburses ASCs at about 50% of HOPD rates.
Orthopedic surgeons also cite policy and payer trends as ongoing challenges. Surgeons are bracing for new and proposed policies that could further reduce pay in 2025 and beyond, including Medicare conversion factor cuts, prior authorization hurdles and rising overhead costs.
Implant costs remain one of the largest contributors to procedure expenses. Vendor pricing, contract terms and surgeon preference can significantly affect whether cases remain profitable in the outpatient setting.
Administrative requirements also add costs and delays, with prior authorization among the most difficult and underestimated obstacles in surgical scheduling.
“It costs physicians time and money and only delays appropriate treatment,” Klaud Miller, MD, an orthopedic surgeon and medical director of Windy City Orthopedics and Sports Medicine in Chicago, told Becker’s.
Those pressures are set to increase: CMS has announced new prior authorization requirements for certain spine and orthopedic services under Medicare, targeting 17 procedures flagged as vulnerable to fraud, waste or overuse.
Ultimately, all of these factors — reimbursement cuts, implant pricing, administrative burden and regulatory changes — determine not only whether providers can sustain margins but also what patients pay. CMS price transparency data show the difference: rotator cuff repair averages about $6,285 in an ASC compared with $10,258 in a hospital outpatient department.
