As payer denials and prior authorization hurdles continue to rise, orthopedic surgeons continue to face pressures to getting paid.
Two surgeons connected with Becker’s to share the biggest reimbursement challenges they are currently facing.
Ask Orthopedic Surgeons is a weekly series of questions posed to orthopedic surgeons around the country about clinical, business and policy issues affecting spine care. Becker’s invites all orthopedic surgeon and specialist responses.
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Please send responses to Claire Wallace at cwallace@beckershealthcare.com by 5 p.m. Central time Friday, April 11.
Editor’s note: Responses have been lightly edited for clarity and length.
Question: What is your biggest obstacle to getting paid or reimbursed?
Hrayr Basmajian, MD. Orthopedic Surgeon at Pomona (Calif.) Valley Hospital Medical Center: Orthopedics is not alone when it comes to getting paid or reimbursed. Medicine, overall, is one of the only professions where we provide care with no guarantees or control over what we get paid. Many obstacles and frustrations exist in the financial side of medicine.
If we could start with any of the obstacles, many surgeons would recommend starting with the prior authorization process. This process adds multiple layers of red tape and also loads of work and cost, with no benefit to patient care.
Many times, providers are not able to deliver the best care to a patient sitting right in front of them because no authorization exists. At the same time, we know that with some paperwork and sometimes getting on the phone for an unreimbursed phone call, the payer almost always approves it. So we are forced to add frustration to the whole “delivery of medicine” world.
In addition, many times, even with prior authorization, the payers will deny the payments secondary to a clerical error on either side, not because it is not medically necessary. Politicians have promised to address this issue in healthcare, yet no one has had the strength to stand up to the large insurance companies.
Jeffrey Kachmann, MD. Spine Surgeon at North Texas Brain and Spine Center (Frisco): As a surgeon in the U.S., some of the biggest obstacles I face in getting paid or reimbursed include:
- Insurance reimbursement rates: Often, insurance companies reimburse at rates that are significantly lower than the surgeon’s billed fee. This can be a particular issue for procedures that are complex, time-consuming or require advanced technology, as the reimbursement may not fully cover the costs of performing the surgery, nor will the insurance company understand the complexity needed to achieve desired results.
- Delays in payment: Insurance claims often involve delays in processing, which can result in long waits for reimbursement. This can put a financial strain on surgical practices that rely on timely payments to cover operational costs.
- Denials and underpayment: Insurance companies deny claims for surgery or underpay for services rendered, citing reasons like medical necessity or coding errors. This requires us as surgeons to spend significant time and effort appealing these denials.
- Contractual issues with payers: Surgeons have to navigate complicated contracts with insurance for numerous companies. Some may not be in-network with certain insurers, which could lead to patients being out-of-pocket or the surgeon receiving lower reimbursement rates. Negotiating fair contracts with insurers can be time-consuming and challenging.
Overall, the complexity of insurance policies, reimbursement rates, administrative hurdles and the need for accurate billing makes getting paid and reimbursed a challenging aspect of being a surgeon in the U.S. in this day and age when the main focus should be on patient care and providing the right care for each individualized patient rather than administrative billing reviews and hurdles.
