Prior authorization will slap more hurdles on orthopedic care, providers say

Alan Condon -   Print  |

Orthopedic providers are pushing back against incoming prior authorization requirements, which they say bring increased administrative burdens and take away from time with patients.

The policy requires providers to get permission before delivering certain medical services, with the goal to minimize costly procedures and act as a check on potentially unnecessary, inappropriate or unsafe medical treatments.

Many insurance plans require prior authorization for orthopedic procedures, imaging and medications, but it is becoming an increasing pain point for providers.

In a recent survey from the American Medical Association, 28 percent of providers reported that the prior authorization process affected care delivery and led to a serious adverse event, with 86 percent indicating that the burden associated with the policy in their practice required an average of nearly two business days per week.

"The amount of time I have to spend getting authorization for simple tests is truly infuriating and results in me being able to spend less time caring for patients," said David Gendelberg, MD, a spine surgeon and member of the North American Spine Society's political engagement committee. "Establishing a prior authorization mechanism would allow me to spend more time doing what I love most, seeing and treating patients."

American Academy of Orthopaedic Surgeons President Daniel Guy, MD, echoed Dr. Gendelberg's frustrations in a recent interview with Becker's: "It seems over the last number of months that prior authorization is becoming more and more of a burden for us to be able to order tests and offer treatments that require insurance.

"What we're seeing is a significant uptick in peer-to-peer conversations. There's not anything inappropriate with asking us why we want to do a procedure or a test, but the system is really not transparent."

Spine care providers will soon see increased prior authorizations regulations implemented for Medicare populations.

Beginning July 1, CMS will require prior authorization for two new service categories: cervical fusion with disc removal and implanted spinal neurostimulators. The policies are to ensure Medicare patients receive necessary care and reduce "unnecessary increases in the volume" of covered outpatient spine services, the agency said.

But there has been pushback.

In an April 7 letter to CMS Acting Administrator Elizabeth Richter, a coalition of 40 groups representing providers and medical device companies, among others, said that the new regulations will further delay patient access to "medically necessary care."

Additionally, incoming regulations for neurostimulators would lead to more opioid use and negative physical and clinical outcomes for Medicare patients, the International Society for the Advancement of Spine Surgery said in a Dec. 29 letter to former CMS Administrator Seema Verma.

"We believe it is essential to continue to increase access to nonopioid pain treatment. Spinal cord stimulation and cervical fusion surgery are especially important alternatives to opioid prescriptions," the society said. 

A lack of experience in using prior authorization in fee-for-service Medicare, a lack of administrative structure for implementing the policy and a lack of guidelines through which providers would obtain prior authorization are among other concerns raised by providers.

The overall effect of prior authorization has not been well-documented, but studying this is pivotal to ensuring high-quality care for patients and decreasing administrative burdens for providers, according to an October article published in the National Library of Medicine.

In 2020, CMS implemented prior authorization for five procedures in its outpatient prospective payment system/ASC final rule. Stakeholders opposing increased regulations have called on CMS to hold off on prior authorization for more procedures until it has conducted a detailed analysis of the policy and its effects. 

More articles on practice management:
Florida surgeon performs disc replacement on wrong area of patient's spine
2 spine surgeon leaders exit Johns Hopkins
5 high-profile device company court battles: Medtronic, Smith+Nephew & more 

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