5 Tips for Spine Surgeons to Collect More From Payor Contracts


Here are five tips for spine surgeons to collect more from negotiating better contracts with insurance carriers. 1. Present oDr. Brian Gillbjective quality data to insurance companies. Insurance companies will ask for quality data during contract negotiations. Make sure you can produce information about your individual outcomes and highlight any positive points, such as a lack of complications, return to work status and pain scores.

"It would be in surgeons' best interest to have some kind of objective data such as outcomes data to show insurance companies or workers' compensation carriers to justify what they do and how effective they are," says J. Brian Gill,Dr. Richard Kube MD, a spine surgeon at Nebraska Spine Center in Omaha. "We do research studies on our patients for outcomes on post-surgical patients and look at Ostwestery scores as well as neck disability and return to work status. We compare that to available data for standard rates to show our treatments are as effective if not better."

While insurance companies will ask for this data and inspect it, they are more interested in cost data. Make sure your quality is high and if the cost is also high, defend your high costs by showing value in your outcomes.

"Track outcomes from a clinical standpoint and a patient satisfaction standpoint," says Richard Kube, MD, founder and CEO of Prairie Spine and Pain Institute and Prairie SurgiCare in Peoria, Ill. "Know how you stack up against others. If you can show value for the services you provide from benchmarking, that is substantial."

2. Emphasize the points of clinical differentiation from competitors. The days of being a general neurosurgeon who performs both cranial and spine surgery are numbered as more fellowship-trained specialists enter the field, says Khawar Siddique, MD, a fellowship-trained spine surgeon with Beverly Hills Spine Surgery in California. This is especially true for surgeons practicing in a competitive urban environment. You have to set yourself apart as an expert in spine, and offer better care than other spine-focused physicians in your market.

Additional points of differentiation could include:
•    Concierge services
•    Responsive and caring staff members
•    Rapid turnaround to patient questions
•    Newer technology

Payors such as Blue Cross, Blue Shield, United and Medicare calculate reimbursement based on the procedure performed, and not always on the quality of care. However, surgeons should seek better reimbursement if they can prove their quality is better. One of the ways to differentiate your practice from others is showing your surgical skills are more advanced.

"Emphasize the differentiation, such as different surgical skills if you do minimally invasive procedures, or the fact that you don't have residents or trainees performing the procedures," says Dr. Siddique. "It's important to train surgeons, but the outcome could be different if a surgeon with 10 years of practice performs the procedure as opposed to a second-year resident. One way we are different is that we don't have any residents. We are trying to show the patients that they'll get better care from us and that's why we charge more than other surgeons."

You can also persuade payors by proving your mortality and morbidity rates are better than the national averages, but you must maintain those rates. "You can't just increase prices and do the same procedures as before," says Dr. Siddique. "We emphasize quality over quantity. In our practice, we do fewer surgeries per year but charge more because we can achieve better patient outcomes and experiences."

3.  Offer a broad array of comprehensive services, including pain management. An easy way to ensure lower global costs is by providing the service yourself. It can be cost effective for the insurance company if the practice performs the diagnostics and radiology services, which is also convenient for the patients, says Mr. Beste.

Another service insurance companies will be looking for is pain management. "Low back pain is in the top three in terms of total medical costs of any condition in the country, and more than 80 percent of these cases are non-surgical cases," says Mr. Beste. "To me, the development of a comprehensive service line around the early detection and appropriate management of those patients should signify lower costs. You have to come up with a strategy that can demonstrate to payors how you are adding value."

Most of the non-surgical pain management procedures are performed by interventional pain management physicians, chiropractors, physical therapists and other specialists — not surgeons.

4. Don't undercut others to becomes the lowest cost provider.
When going through negotiations with payors, make sure to hold your ground on your prices. "The worse thing surgeons can do is undercut others by lowering their prices," says Dr. Siddique. "For example, if surgeon X goes to United and charges half as much as surgeon Y, they'll cut the rates for surgeon Y as well. Surgeons must be aggressive and not undercut each other. If you negotiate a bad contract, you have to work twice as hard for your income and the quality of your work will drop."

By going out-of-network, Dr. Siddique says surgeons can signal their outcomes have higher quality than others and demand a fair price. "You can't gouge patients or payors for the procedure, but you don't want to undercut others and lower prices either," he says. "If you are a surgeon from a small town without much competition, you must demand more from commercial payors because you have a position of leverage."

5. Follow through with claim denials. If the surgeon has monitored the patient through non-surgical treatment and the surgeon and patient feel a procedure, such as spinal fusion is the best treatment option, surgeons can ask for pre-approval. In many states, if the insurance company denies approval, the surgeon can still advocate on behalf of the patient to perform the procedure.

"The surgeon may need to undergo additional leg work in developing a response or having a verbal conversation with the insurer's medical director to explain the unique circumstances in the patient," says Greg Przybylski, MD, director of neurosurgery at the New Jersey Neuroscience Institute at JKF Medical Center in Edison, N.J., and president of the North American Spine Society. "Sometimes the conversation and written appeal are successful, sometimes they are not." If the request is still denied, the patient can appeal to the insurer for reconsideration of the treatment. Patients can also pursue insurance coverage from outside their primary company for the procedure.

More Articles on Spine Surgeons:

9 Spine Surgeons on Innovating With Device Companies

7 Best Practices for Increasing Spine Center Profitability

7 Spine Surgeons on Where to Focus Research

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