4 payer updates for spine, orthopedic surgeons to know

Payer Issues

Plans to expand digital prior authorization access and three more updates involving payers and CMS for spine and orthopedic surgeons to know in the last month:

1. Sharonville, Ohio-based Beacon Orthopaedics & Sports Medicine and Anthem Blue Cross and Blue Shield in Ohio are piloting a bundled payment agreement that has saved employers more than $1 million in its first year. The agreement allows more opportunities to perform orthopedic surgeries at Beacon's ASC instead of hospitals.

2. Researchers at New York City-based Hospital for Special Surgery assessed the clinical and financial effects of initiatives for hip and knee replacement patients between 2014 and 2019. During that time, implementation of bundled payment programs at HSS saved CMS nearly $24 million, reduced readmissions and reduced medically unnecessary postoperative treatments.

3. CMS approved The State of Connecticut Health Plan, an episode-of-care payment model. The designation will go into effect Jan. 1, 2022, under an "Episodes of Care" program. This initiative is designed to reduce variations in costs by setting fixed prices for more than 40 common health episodes, including knee replacements as well as spine care aimed to prevent unnecessary surgery.

4. Humana and Boston-based Cohere Health are expanding their partnership enabling a digitized prior authorization process nationwide. They partnered in January, and digital prior authorizations with the platform were implemented in 12 states. The platform uses artificial intelligence and machine learning to automate both provider and payer steps. Ninety-five percent of authorization requests for musculoskeletal services go through the platform, which drives a median approval time of zero minutes.

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