Here are 25 key points on insurance companies, payer rates, spine-specific payer updates and trends related to payer policy to know heading into next year.
Spine-specific payer issues
1. Some payers, including Medicare, are requiring physicians to complete several steps to receive reimbursement for spinal fusion. These steps could include:
• Providing imaging results
• Documenting three months to six months of conservative care
2. Medicare will cover several new spine codes in the outpatient setting next year. The payment may not be very high, but since Medicare now has codes approved other payers may change their policy to include similar outpatient spine surgery codes with a higher reimbursement rate to cover costs.
3. Minimally invasive sacroiliac joint replacements will have a Category I CPT code beginning Jan. 1, 2015.
4. Single-level artificial disc replacement will have a Category I CPT code next year; two-level disc replacement procedures will have a Category III CPT code.
5. CMS is releasing payment data on the most expensive hospital treatments, including spinal fusions. However, the data is "billed" rates, not necessarily what the hospital received for the surgery. The data was released in an effort to promote transparency, but it's difficult to interpret in the raw state.
6. Spine surgery patients with Medicaid have a higher infection rate than patients with private payers, according to a study published in Spine. Infections and complications increase the overall cost of care with readmissions, reoperations and additional hospital stays. Healthcare reform's Medicaid expansion increased the number of people who may need spinal fusion with Medicaid insurance, and could ultimately increase costs if current trends continue.
Best & worst payers
These numbers are from the Medscape Insurer Ratings Report: 2014.
7. The top four quickest payers, among the 11 major payers in the United States, to process claims are:
• Blues plans
• Medicare
• Aetna
• Cigna
8. The slowest payers among the top 11 major payers are HealthNet, Oxford Health Plans and Kaiser Foundation Health.
9. The payers who are speediest and most accurate with responses to questions among the major payers are:
• Blues plans
• Aetna
• Cigna
• Medical Mutual of Ohio
• Harvard Pilgrim Health Care
10. The slowest payers to respond to questions were Oxford Health Plans, Medicare and Humana.
11. The top five payers with the lowest rate of claims denials includes:
• Medicare
• Blues plans
• Aetna
• Cigna
• Medical Mutual of Ohio
Public Policy
12. Only 46 percent of PPACA marketplace enrollees say they're getting a subsidy to help cover their premiums, but the official number shows 85 percent receive a subsidy. Additionally, of those who know they are receiving a subsidy, 47 percent don't know the amount, according to a Kaiser Family Foundation report.
13. The ICD-10 implementation date has been delayed twice, and it could be delayed again. The current deadline is October 2015 — a one-year delay from the October 2014 deadline — but several physician groups are pushing for an additional two-year delay, according to the Journal of AHIMA.
14. The sustainable growth rate has been a controversial topic for several years, as physicians stand to see huge cuts in reimbursement rates without Congress passing continuous bills to prevent them. Some hope the new Republican Congress can repeal and replace the SGR, but NASS advocacy chair John Finkenberg, MD, said in a recent interview the topic is two controversial to attack in the next six months before the 2016 election campaigning cycle begins.
15. The AMA stands behind its initial estimates that ICD-10 will cost $22,560 to $105,506 per practice depending on the size and location. This includes resources towards researching the implementation, educating coders and physicians and updating billing software. Practices could also see a loss during the first few months after implementation if their staff is slower to code and process claims.
16. 59 percent of healthcare providers expect the ICD-10 process to be difficult and the transition to slow their claims processing, according to a RevCycleIntelligence report. Only 6 percent expect their revenue to improve after the ICD-10 transition completes.
Physician observations on payer changes
These findings are from the 2013 Physician Sentiment Index.
17. 45 percent of physicians report payers are becoming more intrusive into the patient-physician relationship.
18. 37 percent of physicians say the time and effort it takes to get reimbursed by payers is increasing.
19. 34 percent say administrative costs to their practice to comply with payer rules and regulations are significantly impacting their bottom line.
20. 27 percent say payers inhibit the care they'd like to give to their patients.
21. 27 percent say the time spent with payers inhibits their ability to spend time with patients.
22. 22 percent say their clinical decisions are being based more on what payers are willing to cover rather than what they think is best for their patients.
Payer mix statistics
These numbers are based on the VMG Health 2012 Intellimarker report on orthopedics-driven ambulatory surgery center payer mix.
23. The average payer mix as a percentage of gross charges for orthopedics-driven ASCs is:
• Commercial payers: 62 percent
• Medicare: 17 percent
• Workers compensation: 11 percent
• Self-pay: 2 percent
24. Payer mix for the top 10 percent of orthopedics-driven ASCs is:
• Commercial payers: 71 percent
• Medicare: 34 percent
• Workers compensation: 34 percent
• Self-pay: 2 percent
25. Payer mix for the bottom 25 percent of orthopedics-driven ASCs is:
• Commercial payers: 54 percent
• Medicare: 11 percent
• Workers compensation: 12 percent
• Self-pay: 2 percent