Retina Insurance Reimbursements of Pediatric Retina Patients in a Hospital versus Outpatient Surgical Setting

PURPOSE: To evaluate reimbursement patterns for pediatric vitreoretinal procedures performed at a tertiary children's hospital versus an ambulatory surgery center (ASC). METHODS: A retrospective review was conducted of retinal procedures in pediatric patients performed between 1/2022 and 1/2025 at a tertiary children's hospital and an ambulatory surgery center in Texas. Self-pay visits and visits with zero billed charges were excluded. The primary outcome was total median reimbursement percentage based on physician-level services. Secondary outcomes included median reimbursement percentage by payer type, public insurer subgroup, surgical setting, and current procedural terminology (CPT) code. The proportion of visits with zero reimbursement was also evaluated. RESULTS: 394 visits from 282 patients were analyzed, including 219 visits at the children's hospital and 175 at the ASC. Median reimbursement was 34.0% (representing 85% of the equivalent Medicare reimbursement rate). Public insurers reimbursed a higher median percentage than private insurers (35.1% vs. 26.5%, P=0.001). Reimbursement was lower at the hospital than the ASC (29.1% vs 36.3%, P<0.0001). 24.1% of visits received zero payment, occurring more frequently among privately insured than publicly insured visits (30.8% vs. 17.3%, P=0.003). Complex retinal detachment repair reimbursed less for private than public insurers (35.4% vs. 42.7%, P< 0.001). CONCLUSION: Private insurers reimbursed lower than public insurers for pediatric vitreoretinal procedures, contrary to patterns commonly reported in adult retinal care. Procedures performed at a tertiary children's hospital resulted in lower reimbursements than those performed at an ASC. Frequent zero-payment encounters, particularly among private insurers, pose challenges that adversely affect the financial sustainability of pediatric retinal care.