INTRODUCTION
The cost of medical procedures in the United States varies dramatically depending on the payment system such as Medicare, Medi-Cal (California’s Medicaid program), private insurance, or lien-based payment models used in personal injury cases.1 A lien is defined as a legal right to a portion of an asset; typically, when physicians offer lien-based payments, the patient immediately receives treatment. The physician is then paid once the personal injury claim is settled or resolved.2 When Medicare or Medi-Cal covers the cost of medical care, the state can place a lien on any settlements or awards to recover expenses provided to the injured party. The California Department of Health Care Services typically asserts the lien through a claim and may pursue recovery through administrative or legal processes if necessary.3 In California, the Judicial Council of California Civil Jury Instruction 3903A establishes that plaintiffs in personal injury cases may recover the “reasonable cost of reasonably necessary medical care.”4 This process highlights the difficulties providers often face in reconciling the low reimbursement rates of Medicare or Medi-Cal with the significantly higher charges in lien-based personal injury cases.
For example, national averages of Medicare reimbursement for an epidural injection can be as low as $500, while costs in personal injury lien cases may reach up to $20 000 for the same procedure.5–7 Lien-based payments can reimburse physicians at a higher rate than their contractual rate with an insurer due to reasons including lack of pre-negotiated insurance rates, risk compensation, delayed payment, and legal negotiations.2 However, these discrepancies can discourage physician participation in Medicare and Medi-Cal and potentially limit access to care for vulnerable patient populations.8 Additionally, in cases where providers charge significantly higher rates, medical expenses may become inflated, increasing the burden on the medical and legal systems and complicating the determination of fair compensation in court. While defining a standard cost for medical care remains complex due to the wide range of reimbursement rates across different payment structures, such discrepancies underscore the importance of determining reasonable expenses for patient care, refining reimbursement models and compensation, and ensuring fairness and consistency in legal proceedings. To address these needs, this study aimed to explore what constitutes a reasonable cost for medical procedures through an anonymous survey of healthcare providers.
METHODS
This study utilized an anonymous, self-administered electronic survey conducted through Survey Legend (SurveyLegend, 2025, Höör, Sweden). The survey was distributed via email to medical providers across multiple specialties, including orthopedic surgery, neurosurgery, anesthesiology, interventional radiology (IR), physical medicine and rehabilitation (PMR), pain management, and physician assistants (PAs) or nurse practitioners (NPs). These medical specialties were chosen due to their direct involvement in performing epidural injections, facet injections/medial branch blocks, and radiofrequency ablation. Survey participation was voluntary, and respondent anonymity was guaranteed by design. The survey was advertised through our institutions’ departmental mailing lists and was encouraged to be further spread via word of mouth. Data collection occurred between February and September 2023.
The 8-question survey aimed to assess healthcare providers’ perspectives on reasonable costs for various medical procedures, focusing on the influence of reimbursement models, specialty differences, and the impact of accepting lien-based payments. Supplementary Table S1 details all questions provided by the survey. The first 2 questions gathered demographic information, including the respondent’s specialty and state of practice. The following 3 questions asked participants to estimate what they believed to be a reasonable cost for 3 standard procedures—epidural injection, facet injection/medial branch block, and radiofrequency ablation—considering all associated costs, such as the surgeon’s fee, facility fee, anesthesiologist fee, fluoroscopy, and supplies. For each of the 3 procedures, participants selected from 5 predefined cost categories: less than $1000, $1000-$4999, $5000-$9999, $10 000-$19 999, and more than $20 000. These categories were specified to evenly span the broad range of charges currently observed for these procedures, utilizing a distribution that captured low-end reimbursements like those from Medicare, and high-end charges seen in lien-based personal injury cases. The sixth question asked participants whether they would offer a discount for cash payments and, if so, what percentage they would be willing to provide. The 2 final questions regarding lien-based payments (1) assessed whether participants accepted lien arrangements and (2) examined the extent to which participants adjusted their charges under this payment model. After the closing date for questionnaire submissions, the results were downloaded as a CSV file for further analysis.
Statistical Analysis
All data analyses were conducted using R version 4.4.3 (R Core Team, 2025, Vienna, Austria).9 Descriptive statistics were used to summarize the participant demographics, including specialty distribution (Supplementary Table S2). Due to an inadequate sample size (n = 2), IR specialty participants were excluded from analysis. The pain specialty group was also composed of both anesthesiologists and PMR, in addition to respondents who identified as only pain physicians, however no significant findings or differences were found when assessing for this component. Pairwise comparisons were conducted to assess the association between medical specialty and lien status vs reasonable value for: (1) epidural injections, (2) facet injections/medial branch blocks, and (3) radiofrequency ablation, as well as the reasonable discounts given to cash-paying patients. The Brant test was performed to test the parallel regression assumption, confirming that the assumption held for all analyses. Additionally, a model comparison was conducted to assess whether there was a significant interaction between specialty and lien status; the interaction was not statistically significant, so the main effects model was retained. Results were reported as odds ratios (ORs) with 95% confidence intervals (CIs), and statistical significance was set at P < .05.
RESULTS
Respondent Demographics
There were 98 survey responses recorded, with 30 responses excluded due to incomplete data, resulting in 68 surveys included in the final analysis. As displayed in Supplementary Table S2, respondents represented multiple medical specialties: 12 (17.6%) orthopedic surgery; 4 (5.9%) neurosurgery; 6 (8.8%) anesthesiology; 10 (14.7%) PMR; 28 (41.2%) pain management, which included anesthesiologists who had completed a pain fellowship; and 8 (11.8%) PAs or NPs. Among all specialties, 28 (41.18%) reported accepting lien-based payments, while 40 (58.82%) did not. Physicians practiced from a variety of locations: 57 (83.8%) in California, 7 (10.3%) in Hawaii, 3 (4.4%) in Minnesota, and 1 (1.5%) “other.”
Estimated Reasonable Costs for Procedures
Table 1 showcases the frequency of perceived reasonable values for each procedure. For all 3 procedures, the most common value was $1000-$4999, chosen by 37 (54.4%) for the reasonable cost of epidural injections, 37 (54.4%) for the reasonable cost of facet injection/medial branch blocks, and 42 (61.8%) for the reasonable cost of radiofrequency ablations. Notably, no respondents considered $10 000-$19 999 to be a reasonable cost for an epidural injection, and only 1 respondent (1.5%) selected this range for facet injections/medial branch blocks. For all 3 procedures, only 2 participants (2.9%) perceived costs to exceed $20 000.
Neurosurgery was significantly associated with higher epidural values compared with pain (P = .025), PMR (P = .029), and PA/NP (P = .04) (Table 2). Neurosurgery was significantly associated with higher facet injection/medial branch block values compared with the specialties of PMR (P = .03) and PA/NPs (P = .01). (Table 3). Neurosurgery was significantly associated with higher radiofrequency ablation values compared with PA/NPs (P = .02) (Table 4). While pain physicians consisted of multiple specialties such as anesthesia and PMR who completed pain fellowships, subgroup analyses within pain yielded no significant findings.
Lien-Based Adjustments and Cash Discounts
Physicians with a “no-lien” status (ie, those who did not accept lien-based payments) were significantly associated with lower procedural values across all specialties and procedures. Specifically, those not accepting lien-based payments were approximately 73.8%, 64.9%, and 76.9% less likely to be in a higher payment category for epidural procedures, facet injections/medial branch blocks, and radiofrequency ablations, respectively (Tables 2, 3, and 4). Additionally, lien status had no significant association with cash discounts (Table 4). There was no significant association with a discount given to cash-paying patients across all specialties (Table 5). Table 6 illustrates frequency of percent discount for cash payments for all procedures.
DISCUSSION
This survey study examined physician perceptions of reasonable costs for epidural injections, facet injections/medial branch blocks, and radiofrequency ablation procedures across multiple specialties. Results were analyzed using pairwise comparisons to assess differences between specialties, lien-based payment status, and any trends with cash discounts. Our survey results suggest distinct variations in cost estimates based on both physician specialty and lien acceptance. Neurosurgeons reported higher reasonable values for all 3 procedures when compared with other certain specialties, such as pain management, PMR, and PA/NPs. Additionally, providers who did not accept lien-based payments consistently reported lower cost estimates across all 3 procedures. These findings complicate the legal determination of “reasonable” medical costs in personal injury cases, as California Civil Jury Instruction 3903A requires.4 Our results show significant variation in what constitutes a fair value for identical procedures within the medical community.10 This inconsistency poses challenges in evaluating the reasonableness of medical billing in litigation settings.
Comparison With Existing Payment Structures
The range of reported reasonable costs by respondents highlights an ongoing discrepancy between physician expectations and existing reimbursement models. Medicare’s estimated $500 reimbursement for epidural injections and facet injection/medial branch blocks, as well as $1000 for radiofrequency ablation, represents one extreme of the pricing spectrum, as it is below both physician-perceived reasonable costs and the inflated charges often found in lien-based cases.5,6,11,12 In contrast, personal injury billing can reach as high as $20 000 for an epidural injection, a cost category that only 2.9% of survey respondents chose.7 The majority of responses were between these extremes, with responses most commonly (56.8%) falling into the $1000-$4999 range for all three procedures (Table 1). However, there were significant responses above and below this category. These findings reflect the broad variability in what providers perceive as reasonable and point to the lack of a standardized value for procedural pricing.13 The variability in perceived reasonable costs also raises concerns about how third-party payers, namely insurance companies, determine reimbursement rates that align with provider expectations. A more explicit definition of “reasonable cost,” in this context, would incorporate not just direct inputs like procedural supplies or physician pay, but also indirect costs such as administrative overhead or delayed payment risk and legal exposure in the case of lien-based payments.2 Expanded physician documentation could lead to more clarity as to what reasonable costs are and more accurate reimbursement.14 From the patient’s perspective, the absence of a consistent pricing framework under lien-based care may result in unpredictable medical costs and challenges in negotiating settlements. This ambiguity could result in exposure to inflated medical bills, reduced settlement proceeds, or protracted disputes over lien reductions.
Impact of Specialty on Reasonable Cost Perception
Specialty-based differences were most prominent in comparisons involving neurosurgeons (Tables 2, 3, and 4), who consistently reported higher reasonable values for epidural injections, facet injections, and radiofrequency ablation procedures compared with pain management, PMR, and PA/NPs. The higher valuations from neurosurgeons may reflect a variety of factors. The length and rigor of neurosurgical training, with a potentially heightened perception of procedural and medicolegal risk, may elevate neurosurgeons’ internal idea of what constitutes fair compensation. Additionally, the fee-for-service relative-value-unit payment model may condition providers like neurosurgeons to view similar procedures through a higher-value lens, leading to the trends found in our results.15 Pairwise comparisons did not reveal statistically significant differences among most other specialties, suggesting that outside of neurosurgery, a relatively shared perception of procedural value exists among the other specialties administering pain management procedures.
Effect of Lien and Cash Discounts on Cost Estimates
Across all 3 procedures, providers who reported not accepting lien-based payments were significantly less likely to report higher-value responses. Those not accepting liens were 73.8% less likely to report higher payment categories for epidurals, 64.9% less likely for facet injections, and 76.9% less likely for radiofrequency ablations. These trends suggest that physicians may adjust pricing based on anticipated legal and financial risk. Because compensation is contingent on the outcome of a personal injury claim, there is a substantial risk that providers may receive a reduced payment, or none at all, if the case is unsuccessful or settles for less than anticipated.16 Personal injury litigation is often prolonged, delaying reimbursement for months to years. To account for this delay and the associated opportunity cost, providers may preemptively raise their initial charges or inflate charges, ensuring that the final negotiated amount still meets their minimum financial expectations.16 All these factors play a part in the wide range and often inflated price of lien-based payments. Furthermore, these lien trends reflect a broader concern about how any non-traditional payment models can distort price transparency. Unlike Medicare or private insurance, lien payments are unpredictable, contingent upon case outcomes, and are frequently reduced through legal negotiation.2 Providers who do not accept liens may only utilize traditional payment pathways that do not hold payment uncertainty, explaining their more conservative perceptions.
The survey found no significant association between specialty or lien status and whether providers offered cash discounts. Table 6 shows that 59% of physicians reported offering a 0% to 20% discount, 31% provided a 21% to 40% discount, and only 10% offered no discount. These findings suggest that cash discounting practices are idiosyncratic and likely influenced by local practice norms or patient demographics rather than systemic factors. This may indicate that cash discounting is driven more by individual or practice-level financial strategies than by broader forces like specialty norms or billing models. However, it remains imperative to refine medical reimbursement models to address discrepancies between insurance contracts and lien-based personal reimbursements. Such improvements may assist patients, particularly those who are underserved or economically disadvantaged, navigate payment strategies more effectively while also promoting fair treatment and equitable compensation.
Limitations
This study has several limitations, primarily regarding the survey design and respondent demographics. The answer choices for reasonable costs were pre-determined categories, which may have limited the precision of responses. Free-text responses could have allowed participants to express more specific perceptions, resulting in more detailed estimates. Additionally, because the responses were self-reported perceptions rather than actual recorded costs, there is potential for bias, as physicians may have leaned toward ideal reimbursement values rather than actual current values.
Respondent demographics were also an important limiting factor. The included specialties did not cover all physicians who performed the surveyed procedures. Including additional specialties could broaden the range of perspectives, picking up on additional trends across different fields or practice settings. Some specialties were represented by far fewer respondents than others. For instance, only 4 neurosurgeons participated, in contrast to 28 pain management physicians. Specialties with smaller respondent numbers could have skewed our results and significant findings regarding neurosurgeons, as well as limited the ability to identify trends across specialties. Furthermore, the exclusion of 30 participants due to incomplete data is a significant number, and the lack of a formal power analysis to justify our sample size remains an important limitation regarding the generalizability of our findings.
Institutional differences and the geographic distribution of respondents may also have skewed responses. While the anonymity of the survey did not allow for the consideration of institutional differences, the majority of providers were located in California (83.8%). Healthcare systems, legal practices, costs of living, and cost expectations vary significantly by location and institution, so our results may not reflect national physician perspectives.17 A more geographically diverse sample would help broaden the study’s perspective and identify geographic trends in physician cost perceptions. Lastly, despite the widespread utilization of Medicare, this study did not consider any other public and private reimbursement plans. Future research should investigate additional comparisons between the vast and diverse selections of healthcare insurances to more accurately determine reasonable costs for procedures.
CONCLUSION
This anonymous survey study examined physician and healthcare providers’ perceptions of reasonable costs for epidural injections, facet injections/medial branch blocks, and radiofrequency ablation procedures across multiple specialties. Results were analyzed using pairwise comparisons to assess differences between specialties, lien-based payment status, and any trends with cash discounts. For all 3 procedures, the most common perceived value for all participants was $1000 to $4999. Neurosurgery was associated with significantly higher epidural values than pain, PMR, and PA/NP; higher facet injection/medial branch block values compared with PMR and PA/NPs; and higher radiofrequency ablation values compared with PA/NPs. Physicians who did not accept lien-based payments showed significantly lower cost values across all specialties and procedures. Our findings offer insight into reasonable expenses for patient care, possibly assisting in refining reimbursement models and ensuring consistency in legal proceedings. Such improvements are imperative in assisting patients more effectively navigate payment strategies while also promoting fair treatment and equitable provider compensation. Future research may investigate comparisons between a broader range of public and private insurance contracts as well as lien-based personal reimbursements to better standardize cost estimates and allow for actionable and tangible policy adjustments.