Payer scrutiny in spine and orthopedic care is intensifying, and surgeons say the biggest barriers to care come not from clinical uncertainty, but from rigid algorithms, prior authorization delays and coverage policies that override medical judgment.
Orthopedic and spine leaders across the country joined Becker’s to discuss where payer rules most interfere with patients getting appropriate care.
Question: Where do payer policies most interfere with patients getting appropriate spine and/or orthopedic care?
Editor’s note: Responses have been lightly edited for clarity and length.
Russell Bodner, MD. Retired Orthopedic Surgeon from Northwestern Medicine (Chicago): Payers use AI cookbook algorithms to deny treatment; these are word-based, not logic-based. Poorly screened denials are then sent to arm’s-length but integrated review companies, where physicians compare the facts to their cookbook requirements to issue what amounts to a medical judicial decree. These physicians may not be specialists or have case knowledge and are closely monitored for their denial rates. Essentially, patient care is being brokered by paid henchmen. That’s their game with our lives.
Houssam Bouloussa, MD. Assistant Professor of Orthopedic Surgery at University of Missouri-Kansas City: When payers align coverage with clinical evidence rather than utilization barriers, patients recover faster and total costs fall, with value measured in function restored and disability avoided, not procedures denied. Treating care as a commodity rather than a professional, outcomes-driven service, poses a real and growing risk to the U.S. healthcare system.
Jimmy Chow, MD. Principal at Summit Hip & Knee Institute (Phoenix): While payers are important for cost-sharing and access to care in the U.S., the trend of them trying to increase profit margins while healthcare costs are rising essentially removes care from Americans. We are seeing rising premiums, decreased payments to institutions and providers, and at the same time, rising year-over-year earnings on the insurance companies’ side. This translates into reduced resources for healthcare, less bandwidth for the patient, and ultimately, lower quality of care.
One of the biggest changes in payer policies is the removal of out-of-network coverage from the marketplace and the private sector. This directly removes choice from patients and further diminishes control in healthcare delivery from providers. While government payers (Medicare, etc) are tasked with cost reduction, this should not be the standard upon which for-profit entities calibrate. There is obviously a surplus in private healthcare. It should be invested directly into patient care. It ultimately will be up to our community to hold private payers accountable.
Brian Cole, MD. Sports Medicine Orthopedic Surgeon, Acting Chair and Managing Partner in Department of Orthopaedics at Midwest Orthopaedics at RUSH (Chicago): The requirement for telephonic peer-to-peer communications for routine care with well-documented and established medical necessity, or for requests involving non-evidence-based care (e.g., physical therapy for conditions that do not respond to it), has hindered our ability to address patients’ true medical needs in a timely manner and has significantly increased administrative costs for the practice. As written, this policy is unsustainable and requires thoughtful dialogue.
Edward DelSole, MD. Orthopedic Spine Surgeon of Keystone Spine & Pain Management Center (Wyomissing, Pa.): The most consequential interference point today is where bundled payment models meet case-mix heterogeneity in spinal fusion. CMS’ Transforming Episode Accountability Model bundles spinal fusion into 30-day episodes with target prices set by DRG and region. This works for single-level fusions — they’re predictable, standardizable and often beat benchmarks. But the model groups complex multi-level fusions, revisions and combined anterior/posterior cases into the same diagnosis-related groups as far simpler procedures. Risk adjustment doesn’t capture the resource gap between a routine L4-5 transforaminal lumbar interbody fusion and a multi-level revision reconstruction under the same DRG code.
True deformity, malignancy and infection cases (DRGs 456–458) are excluded, but many complex cases still fall under included DRGs and will consistently exceed targets. With two-thirds of hospitals projected to lose money under TEAM, the rational response is case-mix steering, deterring high-cost, complex cases through utilization review, pre-authorization hurdles or operational friction for surgeons who do difficult work.
This creates a two-tiered access problem. Patients needing routine fusions will find care easily. Those needing complex spine surgery, who arguably need it most, face mounting financial disincentives. The pressure isn’t on whether fusions get done; it’s on whether the hard fusions get done at the hospitals best equipped to do them.
Marc Greenberg, MD. Minimally Invasive spine surgeon at University Orthopedics (Providence, R.I.): The biggest interference from payer policies comes from the time it takes to obtain pre-authorization and the difficulty of convincing insurers that surgery is medically necessary. For example, we recently scheduled a patient for surgery at our ASC four weeks after their office visit and the start of the pre-auth process. Leading up to the day of surgery, we still didn’t have authorization. We had to escalate, and only then did we get it approved. There was nothing wrong with our submission; insurance simply hadn’t taken the time to review it. That’s the key point people miss: even when all criteria are met, approval can take weeks or months, and patients suffer needlessly.
Convincing insurers that a patient needs surgery is also difficult because many now use AI to screen language without nuance. If I don’t say “PT > 6 weeks,” they may deny an injection, even if the patient has completed six months of therapy and I’ve documented that. Coverage can hinge on using an arbitrary phrase, not clinical reality. Instead of focusing on the patient’s needs, I’m constantly thinking, “What do I need to say to meet this insurer’s criteria?”, not to keep good notes or protocols, but to satisfy shifting documentation rules. We need accountability for wrongful denials where patients clearly met the criteria. Right now, insurers face no consequences for delaying care, likely to save money, while patients pay the price.
David Kalainov, MD. Medical Director of Orthopedics at Northwestern Memorial Hospital (Chicago): Commercial and government insurance network restrictions can impede timely access to orthopedic specialty care for patients who cannot afford out-of-network costs or fee-for-service out-of-pocket costs. Delayed care can lead to greater direct and indirect costs for everyone involved and potentially suboptimal outcomes.
Daniel Kim, MD. Orthopedic Spine Surgeon at Andrews Sports Medicine & Orthopaedic Center (Birmingham, Ala.): I think the major issue is the archaic, algorithmic and rigid utilization guidelines of the payers that lack an understanding of clinical nuance. The most glaring of these issues is in prior authorization and a forced checklist of “conservative measures” that are often ineffective for the problem at hand, wasteful and delay appropriate access to the necessary care. Spine surgery is exceedingly complex, and the details that matter are often beyond the comprehensive ability of current AI or non-clinical staff to process and make the appropriate exceptions to the gatekeeping process.
Steven Ludwig, MD. Division Head of Orthopedic Spine Surgery and Executive Vice Chair of the Department of Orthopedics at the University of Maryland School of Medicine (Baltimore): Spine surgery often requires multiple layers of care (imaging, injections and perhaps surgery), each with its own delay.
Decisions are frequently made by non-spine-trained reviewers using generic checklists, AI and completely lack the fundamental knowledge that acknowledges a patient’s spinal problem, and how the curated surgical procedure, abiding by all of the state-of-the-art principles, achieves operative and patient goals. Even well-indicated cases (e.g., progressive neurologic deficit) can be delayed if they don’t perfectly match policy language.
Thus, delays lead to prolonged pain, neurologic deterioration, lost work and sometimes worse surgical outcomes. This additionally leads to surgeon frustration, emotional exhaustion and burnout.
Thomas McNally, MD. Director of Spine Surgery at Weiss Memorial Hospital (Chicago): Payer policies most interfere with appropriate orthopedic spine care when they override clinical judgment and limit access to the least invasive, most appropriate treatments.
We are increasingly seeing insurers deny procedures that are supported by evidence and clinical experience, removing reasonable alternatives and leaving patients with limited paths forward: either accept a more invasive surgery or live with ongoing pain and disability.
Endoscopic spine procedures are a clear example; despite strong outcome data and clear patient benefit, they are often denied outright. Similarly, newer techniques are frequently labeled “experimental” long after they have moved into mainstream practice. These policies delay care, increase patient suffering, and in many cases, drive higher long-term costs by pushing patients toward larger surgeries that could have been avoided.
Brandon Ortega, MD. Orthopedic Spine Surgeon at Long Beach (Calif.) Lakewood Orthopaedic Institute: Payer policies most commonly interfere with appropriate spine and orthopedic care by delaying diagnostic imaging, mandating step therapy that does not account for structural pathology and restricting timely surgical authorization. These barriers are particularly harmful in time-sensitive neurologic conditions, where delays can lead to irreversible deficits and worse long-term outcomes. Coverage limitations for motion preservation procedures and postoperative rehabilitation further undermine patient recovery and may increase overall healthcare costs. Ultimately, standardized payer algorithms often fail to account for the individualized, anatomy-driven nature of spine disease, creating misalignment between cost-control strategies and evidence-based patient care.
James Rizkalla, MD. Orthopedic Spine Surgeon at Baylor Scott & White Health (Dallas): The greatest interference from payer policies occurs around prior authorization requirements, therapy mandates and arbitrary imaging or conservative-care thresholds that are not aligned with clinical reality. In spine and complex orthopedic care, these policies often delay timely surgery or advanced interventions for patients with clear neurologic compromise, progressive deformity or failure of appropriately selected nonoperative care. At Baylor University Medical Center, we see firsthand how administrative barriers, rather than clinical judgements, can prolong pain, worsen functional decline and ultimately increase overall cost by delaying definitive treatment. Aligning payer policies more closely with evidence-based guidelines and subspecialty expertise would significantly improve patient outcomes and care efficiency.
Katherine Wagner, MD. Neurosurgeon at Ventura (Calif.) Neurosurgery: Payer policies regularly interfere with my ability to get things done quickly. For instance, my office is a few hundred feet away from the hospital and a quick walk to both Quest and Labcorp. I can’t just send patients over to these facilities to get their pre-operative labs, chest X-ray and EKG. I have to wait for insurance to approve it, and then, my team has to coordinate getting the patients to the labs and getting the results sent to us for review. Things would move much faster if I could just get patients their tests while they are here; this is especially true for my elderly patients who have caregivers and require rides.
Prior authorization for surgery can also be challenging. Recently, a large carrier told me they would only cover an allograft and plate for my patient who needed an anterior cervical discectomy and fusion. That is an older surgical technique, and many surgeons have migrated to using titanium or polyetheretherketone cases with or without a plate. When I was planning my appeal, I found that multiple neurosurgery organizations and spine surgery organizations had already asked this very carrier to adjust their policy several years ago. The carrier never adjusted their policy, and I wasted time appealing and moving the patient’s surgery. This creates problems for every party, except the insurance carrier.
Unfortunately, it is exceedingly hard for most patients to afford spine and orthopedic care without their insurance. We are stuck playing games and pandering to the payers’ whims while our patients and schedules suffer.
Jeffrey Wang, MD. Chief of Orthopedic Spine Service and Co-Director of the Spine Center at the University of Southern California (Los Angeles): I think the more urgent situations that require some type of more immediate action are where their policies can be a bit of a hindrance: if there is an urgent need for a new imaging study due to new worrisome symptoms, or a need for an injection very soon to control a patient’s pain, for instance. Many times, we need to send the patient to the nearest emergency room in order to expedite their care, showing the insurance company the urgency of the situation.
Aqib Zehri, MD. Neurosurgeon at The Oregon Clinic (Portland): Payer policies most often interfere through delays and denials around imaging, procedures and surgery, even when there’s a clear medical reason to move forward. Patients are often required to try a series of lower-level treatments first, which can slow care for people already dealing with disabling pain, neurologic symptoms or loss of basic function.
In spine care, especially, these one-size-fits-all rules don’t always account for complexity, and that can make it harder to deliver timely, patient-specific treatment.
Christian Zimmerman, MD. St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): The inertia surrounding the approval processes for third parties and governmental payers, and the expected course of action for surgical endorsement has become an inveterate convention.
Largely, most payer policies in dealing with surgical recognitions are timely and acknowledged when progression of signs, symptoms and submission of appropriate modalities are gathered. The more discerning cases, such as mismatched data, the continuum of conservative therapies and requisition for revisional and salvage work, require expectantly more prudence. Over the decades, the paroxysmal growth of spinal implantation carried its own burdensome complexities and usually resulted with transfer of care and supplementary procedures when acuity or insurance turbulence arose. Weightier multisegmented or prophylactic procedures have fortunately fallen under added scrutiny for outcome and cost-benefit. The current canting of necessary care delivery remains appropriate with all denials being open for appeals. Most of these processes are proportionate in evaluation and result in approval.
