Ventral Hernia Repair: Will Your Insurance Cover the Procedure?

If you’ve just received a ventral hernia diagnosis, you might feel nervous about the next steps—and understandably so. Not only are you looking at an upcoming surgery, but the cost of a surgical procedure can be incredibly high in the United States.

The big question is if insurance companies cover a ventral hernia repair in Orange County, CA. Keep reading to find the answer and discover all you need to know about paying for a hernia repair.

The Basics of Ventral Hernia Repair

Generally speaking, ventral hernia repair involves pushing the intestine or tissue back into place and repairing the weakened abdominal wall. Depending on the type of hernia and surgery, the surgeon may use both stitches and a mesh piece or just stitches to close the internal abdominal opening.

There are four main types of hernia repair procedures that a surgeon might recommend:

• Open surgery: In this traditional hernia repair approach, the surgeon makes a large abdominal incision to manually address and repair the hernia. This procedure involves a longer healing process because of the large incision, so it’s usually only recommended when absolutely necessary. Emergent or complex hernias typically require open surgery for the best results.
• Laparoscopy: Laparoscopy is a minimally invasive hernia repair option. Instead of opening the patient up with a large incision, the surgeon creates several small incisions around the hernia and inserts long instruments equipped with a camera.
• Robotic Surgery: Like a laparoscopy, robotic surgery includes tiny incisions and long, thin instruments. The difference is that the robotic instruments offer enhanced agility and precision for an even more minimally invasive approach.
• Single Incision Robotic Surgery: This is the best option for minimally invasive hernia repair and quick recovery time. Instead of several small incisions, this approach uses just one. The surgeon then inserts the robotic instruments into the incision for increased precision.

While the ideal repair option is, of course, the single incision robotic surgery, it’s not always an option. Patients with advanced or large hernias often need a more invasive procedure to ensure a successful repair, as do patients with complex medical conditions.

Talk with a hernia repair specialist to see what procedure ensures the safest and most successful results for your situation.

Understanding Health Insurance Coverage

Health insurance helps reduce the cost of healthcare in the United States. People who select their own health insurance plan pay a monthly premium—or a monthly bill—for that coverage. Patients who have insurance through their job may pay some or none of that monthly premium, as their employer takes on most of those expenses.

Aside from those premiums, an insurance company charges copays, deductibles, and coinsurance.

• Copay: A copy is a minimal fee that patients pay for every doctor appointment, prescription, and emergency room visit.
• Deductible: The deductible refers to the maximum yearly amount the patient must pay toward healthcare expenses before the insurance company starts paying anything. Copays do not count toward the deductible.
• Coinsurance: Some insurance plans include coinsurance, meaning that patients must pay a portion of the healthcare expenses after the deductible. For example, the insurance company might agree to pay 85% of the bills after the deductible. That means the patient must pay the remaining 15% until they reach a pre-established maximum.

The combination of these fees totals the patient’s out-of-pocket maximum.

So, how does this apply to surgical procedure coverage? First, patients must pay a copy for each surgical consult. The amount they pay for the actual procedure depends on how the patient has paid toward the out-of-pocket maximum.

Let’s say the patient’s deductible is $3,000, and they have not paid any of that before having hernia repair surgery. They must then pay the full $3,000 before the insurance company covers any portion of the surgery. And then there’s the coinsurance. After the deductible is met, the patient still needs to pay the percentage stipulated in their policy.

Of course, some insurance policies have very low deductibles and coinsurance maximums. Depending on the patient’s individual policy and how much they’ve already paid toward their yearly out-of-pocket maximum, they could be paying close to nothing or a large portion of the total cost.

The Role of Medical Necessity in Insurance Coverage

When determining whether an insurance company will cover an operation, it uses a term called “medical necessity.” If the insurance company determines a procedure is a medical necessity, they usually partially or fully cover it.

The National Association of Insurance Commissioners defines a medical necessity as something that:

• Isn’t just for convenience
• Isn’t an investigational or experiment procedure
• Is required to diagnose or treat a disease, injury, or health condition

This definition changes the traditional belief that insurance companies don’t cover elective surgeries. Patients can elect to have a non-emergent procedure to help diagnose or treat a health condition—and the insurance company will still cover at least a portion of the costs.

Ventral Hernia Repair and Insurance Coverage

With that definition in mind, most insurance companies—if not all—will cover a ventral hernia repair. While many hernia repair operations are elective and non-emergent, they are still medically necessary to treat a health condition.

The major question is how much of the repair the insurance company will cover, and that generally comes down to each patient’s policy. The best way to know for sure how much you’ll need to pay out of pocket is to contact your insurance provider and ask.

Cost of Ventral Hernia Repair without Insurance

The cost of ventral hernia repair varies greatly and depends on several factors.

• Type of procedure: A laparoscopy or robotic surgery is often more expensive without insurance than open surgery because of the tools and technology involved. However, that extra cost is well worth the quicker recovery time for many people.
• Complexity: While an open surgery may cost less because of the instruments needed, the price increases with the surgery’s complexity. For example, the final cost can skyrocket if the patient has other abdominal conditions, underlying conditions, or a complex hernia.
• Surgery facility: Patients who receive inpatient hernia repair (in a hospital) can expect to pay much more than those who seek outpatient services. In emergent situations, an inpatient procedure might be necessary. But if patients take a proactive approach and get the hernia repaired early on via an outpatient clinic, they can save a lot of money.
• Location: Prices vary across the country. Some states charge much more for hernia repair surgery than others—and even then, the price typically fluctuates from one county to another.

So, what’s the actual cost? Clinics and hospitals consider the factors above and then calculate the cost of surgeon fees, facility fees, anesthesia, and equipment like a hernia repair mesh. Patients without insurance must pay that entire amount, typically under $10,000.

According to New Choice Health, the national average price for a laparoscopic hernia is $8,187, while the national average for an open hernia repair is $7,325. These numbers show that open surgeries are generally cheaper, but not by much.

Another way to predict the cost of a ventral hernia repair without insurance is to look at state averages. Sidecare Health estimates the average price for hernia repairs in California to range between $6,293 (at a surgery center) and $9,034 (at a hospital).

Tips for Ensuring Your Procedure is Covered

As mentioned above, contacting the insurance provider is the best way to ensure the hernia procedure is covered. Ask about inpatient and outpatient coverage, which may help determine where the procedure occurs. If scheduling an outpatient procedure, talk to the clinic and ensure they accept your insurance before scheduling a consultation.

Once you know if the insurance provider will cover the procedure, you can strategically schedule the surgery to lower the deductible.

For example, let’s say your deductible is $3,000 for the whole year, and you don’t have the cash on hand to make a lump-sum payment. You can wait until the end of the year to schedule the hernia repair surgery, so you make gradual payments toward that deductible with other doctor’s visits and appointments. By the time the hernia repair comes around, you might have $1,000 or less left on the deductible, meaning the insurance company will pay the bulk of the costs.

If, for some reason, the insurance provider denies coverage for the ventral hernia repair in Orange County, CA, you have the right to appeal that decision. You can ask the insurance company to conduct a review or contact an independent third party for an external review.

Conclusion

Preparing for a surgical procedure can be nerve-wracking, especially when you know that a medical bill is looming in the future. However, you can remove some of that anxiety by contacting your insurance company and asking about their hernia repair coverage.

The good news is that ventral hernia repairs in Orange County, CA, are usually deemed a medical necessity, meaning most insurance companies will cover them. But you should still talk to your insurance provider to see how much of the procedure they will cover before scheduling it.

Contact Us