Here are 10 points discussing the challenges of spine surgery reimbursement today and where the trends are heading in the future.
1. Payor's coverage criteria and guidelines are changing. Payors are using a different set of guidelines for covering spine surgery; many are based on variations of the Milliman guidelines. Some surgeons argue that the Milliman guidelines are inappropriate because they are based on outdated studies and written by non-medical professionals. Regardless of the source, surgeons should know the payor's guidelines and have an understating of how they can ensure coverage in the future.
"You really need to have an understanding of the criteria for coverage so you know why they are sending denials," says Jeffrey A. Goldstein, MD, director of the spine service and associate director of the spine fellowship at NYU Langone Medical Center's Hospital for Joint Diseases. Dr. Goldstein is also a board member of the International Society for the Advancement of Spine Surgery. "If they say it's based on Milliman criteria, you should have a copy of that. Insurance companies or professional societies should be able to provide you with these guidelines."
This is especially true for lumbar fusions. "Milliman guidelines that drive insurance company policies continue to become stricter in their criteria for approval for lumbar spine fusion surgeries," says Dr. Goldstein. "It's important to know exactly what each insurance company requires before submitting for pre-authorization."
Spine surgeons and societies are now working on updated guidelines for appropriate care, but these efforts are still in their early stages.
"We have reached a defining moment in spine surgery for United States reimbursement where surgeons must engage politically and hold their medical societies accountable," says Dr. Goldstein. "To ensure continued patient access to appropriate spine care, it is critical the various spine societies collaborate on developing treatment guidelines that are reflective of the current standard of care. These guidelines should be the driving premise for all payor coverage guidelines."
2. Denials are more common today than ever. Spine surgeons are seeing more denials today than ever for various reasons. According to Dr. Goldstein, some of the most common reasons for denying spine surgery include:
• Not medically necessary or a poor indication
• The surgery is experimental
• Conservative therapies were not met or structured physical therapy wasn't documented
• Medical terminology for the surgeon's dictated notes and imaging reports did not match the insurance company's medical guidelines terminology for approval
• When submitting the preauthorization, the surgery indicates an acronym
• Additional tests to the MRIs or CTs are necessary, including flexion/extension or nerve study tests
• Bone morphogenic protein use is not FDA approved for off label requests
"A core issue in spine surgery denials are the number of treatment variables and algorithms that are either not clearly defined and defended by any spine surgeon societies or interpreted by non-surgeons and opportunistically converted into restrictive commercial payor coverage policies," says Dr. Goldstein. "There is no doubt that spine continues to rapidly evolve which inherently creates complexity; however, until the insurance 'industry' reflects treatment guidelines driven from spine surgeons and societies there will be a foundational disconnect."
The appeal is often time consuming for the surgeon and their staff members to gather all the necessary information and present it to the insurance company every step of the way. However, the appeal is necessary for advancing coverage.
"It is important that surgeons attempt to appeal an implant or procedure denial rather than acquiescing," says Dr. Goldstein. "When offered an alternative upon prior authorization, it is critical the surgeon consider the best option for the patient, not the easiest pathway to approval."
Services such as the Spine Care Alliance can represent patients after all denials through conventional means have been exhausted.
3. Payors are demanding more documentation. Spine surgeons across the country are hearing they need more documentation from each case before payors will approve surgery. Sometimes surgeons can predict the type of documentation they will need, such as proof the patient took the appropriate pathway of physical therapy and epidural injections before deciding upon surgery; other times, the missing documentation isn't quite as clear.
"Sometimes when you are asking for approval on the big ticket items, payors aren't very straight forward about what you need in your documentation," says Christopher Kauffman, MD, a spine surgeon in Nashville, Tenn., and chair of the North American Spine Society's Professional Economic and Regulatory Committee. "You can tell them how long the patient has been having problems and show them they've been through the treatment pathway, but the payor will still deny surgery because you don't meet all the requirements, but they won't tell you what the requirements are. I can't do a good service for my patients if I can't answer these questions."
Gathering all the documentation necessary can be challenging for spine surgeons, especially when patients have their non-operative care elsewhere.
"Often, the primary care physician has overseen the non-operative care and we may not have put all the medications, physical therapy and ESIs performed in our notes," says Dr. Kauffman. "The insurer sees that this is the patient's first visit to the surgeon, so they assume the patient hasn't done anything else and isn't a candidate for surgery. Payors think they are approving too much too often; they are of the opinion that surgeons have had it too easy for too long and surgeries were approved just because surgeons said they needed it done. That's why there are stricter guidelines and more denials today."
4. Insurers won't cover lumbar fusions. Surgeons are having the most trouble obtaining approval for lumbar fusions, especially in the absence of gross instability. "Payors are really hitting lumbar fusions hard and they are saying 'no' more than they are saying 'yes'," says Dr. Kauffman. "Any time you do a multilevel fusion, that's a big red flag and insurance companies are denying them right away. Lumbar fusion is going to be the catch phrase for years to come."
Surgeons seeking approval for lumbar fusions in patients with degenerative disc disease, a once common diagnosis for spinal fusions, are now being asked to provide extensive documentation and are often still denied. There are some times when the diagnostic tests may not support the diagnosis of instability, and in those cases the surgeons must do extra work for approval.
"Many times insurance companies are denying coverage because there isn't instability recorded on the MRI, but an MRI isn't necessarily a test of instability," says Dr. Goldstein. "You have to explain why you see things that the radiologist didn't see, like images from your standing X-ray showing instability. You have to advocate for your patients."
The increased scrutiny on lumbar fusions has made patients jump through hoops for coverage, even after they follow the treatment pathway. "Most patients don't want to follow up with the surgeon for a year before surgery as they go through non-operative care," says Dr. Kauffman. "They often have done that already with their primary care physician. It costs them money and time to go through the process again, and it becomes onerous to the patient. Surgeons have to get better at documenting everything, even all of the care rendered by other providers."
5. Payors are investigating each case more deeply. Today's payors are investigating cases more than ever; it's not enough to show them the patient is indicated for surgery—now they want to know all the details of the case from how surgeons will approach the surgical site to what implants and instrumentation they will use. When payors contact surgeon offices, front desk staff don't know these details; surgeons must spend their time describing the case to payors before it begins.
"Payors want to know whether you are going to do an anterior, posterior or lateral approach; what cages and screws you are going to use; what kind of bone graft will be used," says Dr. Kauffman. "United has just come out with an extensive policy severely limiting the type of bone graft that is acceptable. They are trying to limit the newer synthetic types of bone graft; sometimes there is a reason we want to use that graft, but there is no room for exceptions.
For example, Dr. Kauffman's practice serves a large population of Jehovah Witnesses and they won't take an allograft; if they can't use an iliac crest donation, the newer synthetic bone grafts are their only option. "When you get the insurance company on the phone, they say that isn't their problem," says Dr. Kauffman. "But allografts are against the patient's religion."
These questions lead to ethics issues among spine surgeons. "If an insurance company is going to authorize a one-level spinal fusion, the company shouldn't be saying whether you can use a specific implant or technique," says Dr. Goldstein. "I don't think there is any data suggesting one procedure is better than the other; it depends on the surgeon's expertise and comfort. The insurance company is really crossing the line in those situations by treating a patient who they've never seen."
6. "Peer-to-peer" reviews aren't with a "peer." When insurance companies deny coverage for spine surgery, surgeons can appeal that decision to a "peer-to-peer" review. In many cases, the insurance company's "peer" isn't a spine-focused surgeon and often is no longer a practicing physician.
"Your first appeal will be peer-to-peer, which might mean you are speaking to a retired pediatrician," says Dr. Goldstein. "That isn't a peer. Your peer is a surgeon who is practicing in your subspecialty. Even doing a peer-to-peer with a sports medicine surgeon would be a stretch for a spine case."
Ask the insurance company's reviewing surgeon for their qualifications to see whether they are a practicing spine surgeon. "Spine surgeons have to wait until the insurance company's 'expert' is available and it might be a radiologist," says Dr. Kauffman. "That's not an appropriate person to go over spine cases. It can be very frustrating."
7. Payor medical directors are becoming more involved in coverage decisions. If the "peer-to-peer" review and other steps of the appeals process fail, surgeons can approach the payor's medical director and advocate for coverage. These individuals can be an influential partner in gaining approval for patients with individual considerations.
"Spine surgeons should talk with the local and regional medical directors regarding the basic principles of spine surgery and share the clinical outcomes of well-selected spine care patients," says Dr. Goldstein. "Continued appeals for inappropriate denials are critical to ensure focus and pressure on changing the coverage policies that drive them. Quite frankly, I have generally been successful advocating for my patients when I personally approach the medical director or peer-to-peer with a good understanding of why the procedure I am recommending does in fact fall within the carrier's medical guidelines."
8. Surgeons are collecting more data on their cases. Since insurance companies are questioning cost effectiveness and quality outcomes of spinal surgery today, surgeons are spending more time collecting data to prove their procedures work and are actually saving the healthcare system money in the long run.
"We as physicians have to position ourselves so we are collecting data," says Dr. Kauffman. "This doesn't mean that everyone has to be a researcher in a big academic institution, but surgeons should record their surgeries and results in a registry. It's hard to do business now and see the results several years down the road, but this level of follow up is going to be necessary to prove surgery works. Insurance companies assume it doesn't work and we have to document our patient outcomes to show efficacy."
Some insurance companies are denying surgery because there isn't enough long-term data to support the procedure, even when there is five to seven year follow up data. "Some insurance company policies are looking to broadly deny coverage for what they perceive to be an expensive area of surgery, saying there isn't long term level one data," says Dr. Goldstein. "We have five to seven year data, and they don't have that many years in other subspecialties. It's expensive to generate data, especially when they use their own criteria, which are not objective, to deny care."
9. RAC audits could retrospectively deny coverage. RAC audits are becoming more common and could make an impact on spine surgeons' practices in the future. Even if surgeons are able to gain approval for surgery, perform the surgery and receive reimbursement, if a RAC auditor retrospectively finds you didn't have the right documentation for surgery they'll request a refund.
"The Medicare RAC auditors will give you the appropriate or updated guidelines, but that is for the future," says Dr. Kauffman. "They will want their money back for the past cases. Surgeons are not going to know what to do in this situation. They have to have the right documentation both in their office notes and in the hospital record; EMR can give people an advantage in this realm because if your practice takes the time to have different templates for herniated discs, spinal stenosis, ect., you can add to that template continuously and make sure the person has taken the right pathway for fusion. That gets the surgery approved and helps you on the back end."
EMR can help surgeons document for Medicare and private payor cases. If you don't have EMR, staff members can help you make sure patients have been through every step of the treatment pathway before requesting surgery.
"Staff has to help you make sure to schedule the patient for surgery and look at the checklist for the treatment pathway to point out if something hasn't been done yet," says Dr. Kauffman. "They can highlight what you need to do to help the patient get approval when surgery is the next step in their care."
10. Spine societies are becoming increasingly involved in surgeon advocacy. Spine societies are becoming more involved in advocacy efforts on behalf of spine surgeons and their patients to ensure appropriate coverage and reimbursement in the future. More surgeons are also becoming involved in these organizations and working within them to affect change.
"Work with any society, including your local state society, to make a difference," says Dr. Kauffman. "That's the only way you are going to affect any change; have your results and work with your state, local and national societies because that's the only way we have a voice."
Even if the surgeon can't directly participate in the advocacy efforts, contributing financially to the society or engaging in a conversation about position papers and guidelines can make a difference. "Surgeons must take on the role of a surgeon advocate and support our societies," says Dr. Goldstein. "The role of the societies will be even more important as surgeons become busier; they will rely on societies to be their advocate."
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