What are the biggest payer problems for orthopedic practices?


Understanding how to navigate payer relationships is critical for orthopedic practices to succeed. Three surgeons spoke to Becker's Spine Review on the biggest challenges they see with payers. 

Question: What is the biggest payer problem in orthopedic practices?

Mihir Patel, MD. Orthopedic Surgeon and Treasurer of OrthoIndy (Indianapolis). Providers focus on the patient first, then finances. Insurance payers focus on finances, then their clients and then patients. Given the incentives are different, the challenge remains on a daily basis to be a patient advocate. Prior authorizations for advanced imaging or routine procedures, which help determine definitive treatment in today's world, is analogous to using a typewriter on a regular basis. Even more challenging, and some would call absolutely crazy, are so-called peer-to-peer calls after the patient is healed from a procedure and is doing well. 

Nitin Khanna, MD. Spine Surgeon and Founder of Spine Care Specialists (Munster, Ind.).​ The pre-certification process is broken. Government intervention is needed that would hold insurance companies accountable for denials of surgery and diagnostic testing. A Department of Justice investigation should expose these business practices when primary care physicians are denying spine surgery through a peer-to-peer call. Premiums continue to rise for employers, and access continues to decrease. 

This is an unsustainable model. Conceptually, a large orthopedic group's size and market dominance should drive contracting. However, this is not always the case. Insurance companies have gotten bolder and more hostile in their approach to providers. This has spurned the entrance of private equity into health care with surprise billing associated with anesthesia, neuromonitoring and emergency medicine, just to name a few. A reasonable rate of reimbursement directly to independent providers would drive cost savings and increase access and quality of care. 

Andrew Bush, MD. Independent Orthopedic Surgeon at Central Carolina Orthopaedics Associates (Pittsboro, N.C.). A pattern that we have noticed emerging is that insurance companies are more routinely denying tests such as MRI and CT scans and requesting peer reviews prior to authorizing the studies. 

Also, we recently had a Blue Cross Blue Shield policy deny a surgical knee arthroscopy due to something like lack of sufficient evidence, but be willing to authorize the surgery if I agreed to make it a diagnostic arthroscopy — which would cut my reimbursement in half. I refused BCBS for obvious reasons. The patient ended up paying out of pocket for the case, and I ended up doing the surgery I initially indicated. 

One other major issue that we are facing is the CMS ruling that all joint replacement surgeries are now considered outpatient procedures, so the only way that I can post a patient for a total joint is if I post it as a same-day procedure. I have a very unhealthy patient population — typical rural practice with patients with chronic obstructive pulmonary disease, diabetes, heart disease, renal disease and obesity. I feel that it is inappropriate for me to be indicating a patient for an inappropriate hospital length of stay.

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