This article is sponsored by Specialty Healthcare Advisers.
Here are six big trends in spine surgery reimbursement.
1. Payers are demanding more documentation. The documentation insurance companies demand includes data about non-surgical treatment — previously compiled by primary care physicians or non-operative specialists — as well as the appropriate diagnostic and imaging studies. Other times, surgeons have difficulty pinpointing why payers denied coverage. Denials arrive because not all requirements were met, but the unmet requirements aren't specified.
"Spine Surgery practices often receive prior authorization for procedures on the primary procedure code alone," says Carolyn Neumann, BME, CPC, Senior Manager, Coding & Coverage at Access Specialty Healthcare Advisers. "When the claim is submitted, a denial states only 'experimental/investigational.' The entire procedure is denied due to an unstated element not being covered. Forcing a detailed prior authorization, with all technologies and codes included for review, is becoming necessary to avoid this happening. Proactive, documented medical necessity and procedure details must be made available to payors and facilities."
2. More CPT codes are now bundled. In 2012, the new CPT regulations bundled more codes with a high level of service reimbursement, such as the interbody and lateral fusion codes as well as the removal of old instrumentation and insertion of new instrumentation in revision surgeries. Typically reimbursement declines when codes are bundled compared with rates for separately billed codes. The bundling trends are likely to continue with additional updates next year.
"In addition to bundled permanent CPT codes in spine, CPT temporary Category III codes, representing 'new technology’ are almost always highly bundled," says Ms. Neumann. "For example- CPT Cat III code 0275T, reporting lumbar percutaneous decompression, includes the imaging, single and multiple levels and is reported only once for unilateral or bilateral procedures. Per bundling these add on services would be reported and reimbursed separately."
3. Preauthorization is more rigorous. Especially with more expensive procedures such as spinal fusions, insurance companies are sending more frequent denials, forcing surgeons to spend time in the appeals process. The process includes a peer-to-peer review, and often the insurance company representative isn't a spine specialist. Pending continued denial, surgeons complete three or four levels of appeals, which means less time to see new patients.
"In our Reimbursement Management Center, we process prior authorization and claim denials daily for spine surgeons and new technologies," says Ms. Neumann. "Techniques that work to overcome these roadblocks are time consuming and require extensive knowledge of not only the particular payor policies but process that gets them approved."
4. Payers changing policy language to deny coverage. New policy language can deem procedures as "not medically necessary" because the insurance company feels there is insufficient evidence to prove better outcomes than other treatment. For example, Aetna added policy language to the July 2013 Clinical Policy Bulletin update denying coverage for spine cages during cervical fusion procedures.
5. Pay-for-performance measures move toward bundled payments. These new models, such as bundled payments, value high quality care over patient volume. Bundled payments would reimburse for an entire episode of care with one lump sum. Complications within a certain postoperative period, typically 30 to 90 days, are not covered. As a result, spine surgeons are assuming leadership over more aspects of the spine care continuum.
6. Protocol developed by insurance companies. Programs requiring specific treatment pathways for reimbursement in spine care are appearing in several states. Often these programs require patients to see a designated non-operative specialist first to learn about alternative treatment options and sometimes triage care. This trend could mean surgeon offices would fill with more targeted patients who are surgical candidates.
More Articles on Spine Surgery:
The Business of Spine: 7 Step to Balancing Patient Care & Practicalities of Medicine
5 Spine Surgeons on Finding Fulfillment in Their Practice
Reimbursement & Coding Challenges for Outpatient Spine Surgery: Q&A With Carolyn Neumann