5 Biggest Payment Problems in Spine & Pain


SurgeonHere are five big payment issues in spine and pain patient care for this year.

1. Payers require more documentation before approval, especially with spinal fusions. Surgeons increasingly report insurance companies denying approval for spinal procedures without extensive medical necessity documentation and conservative treatment records. Traditionally, primary care physicians provided this information but now payers require surgeon offices to gather this documentation and present it for approval.


"It is not uncommon for my scheduler to spend eight hours per case trying to get approval. If you do the math, you figure out I am losing money trying to be able to take care of my patients," said David W. Polly Jr., MD, during the North American Spine Society Annual Meeting.


Additionally, 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 denied coverage for spine cages during cervical fusion procedures.


High deductible plans are becoming common in healthcare and patients are reluctantly taking on more and more responsibility for the cost of care. Payers may still approve surgery for patients with these high deductible plans, but spine surgeons need to have a plan upfront with patients to improve collections. Patients could be responsible for up to 30 percent to 50 percent of the bill. Transparent conversations with patients will increase the likelihood of achieving payment in full.


2. Payers creating pathways for spine care coverage. Insurance companies in several states are updating requirements for spine surgery coverage, in some cases dictating specific patient pathways. For example, HealthPartners in Minnesota adapted the gatekeeper approach of medical spine management using performance metrics for both specialists and primary care physicians. Back pain patients are required to visit an approved non-surgical back pain specialist before the insurer will cover a visit with a surgeon.


Similar programs are sprouting up with payers in states such as Wyoming and New York to develop patient triage that require a slew of non-operative care before the patient is able to see the surgeon.


3. Physician fee schedule change for pain procedures forcing office-based physicians to consider ASCs. The Centers for Medicare and Medicaid Services posted the final rule for 2014 physician payments significantly decreasing the rate for in-office pain procedures. As of Jan. 1, reimbursement for an epidural injection is $40, and could be even lower if cuts are made related to the sustainable growth rate.


However, the facility fee remains available for physicians performing cases in a licensed, Medicare-certified ambulatory surgery center. Several interventional pain physicians are considering either upgrading their office or moving locations to become an ASC, a significant time and financial commitment.


4. Switch to a pay-for-performance environment. Healthcare is moving toward pay-for-performance initiatives such as accountable care organizations, bundled payments and other shared savings programs to share risk between providers, patients and insurance companies. Hospitals are often at the helm of these organizations, which means they control payment distributions.


William T. Couldwell, MD, president of the American Association of Neurological Surgeons, outlined a few key concerns for neurosurgeons participating in ACOs in a fall 2013 edition of AANS Neurosurgeon:


•    Within ACOs, hospitals are paid a fixed amount and neurological surgery could be a high-cost liability instead of a high-paying specialty.
•    Hospitals often control the distribution of income for ACO members, and neurosurgeons may need to defend the relative value of their contribution.
•    When the ACO achieves its goals to provide higher quality care at a lower cost, insurance companies have little incentive to increase resources over time.


In a study published The Spine Journal, researchers from The Johns Hopkins University School of Medicine department of neurosurgery analyzed current trends in hospital and surgeon fee distribution for lumbar laminectomy. Surgeon professional fee billing was $6,889±$2,882 and collection was $1,848±$1,422 — 28 percent overall, 30 percent for private insurance and 23 percent for CMS.

Hospital billing on average for the inpatient stay, with surgeon professional fees subtracted, was $14,766±$7,729 and average collection was $13,391±$7,256 — 92 percent overall, 91 percent for private insurance and 85 percent for CMS. The researchers concluded that focusing only on physician reimbursement as cost savings strategy would not lead to a substantial drop in overall costs.


5. Bundled codes lower reimbursement for spine and pain procedures. Over the past few years, CPT updates have bundled spine procedure codes that were previously separately billable. As a bundle, the entire procedure is reimbursed less. Key examples include:


•    Interbody fusion codes
•    Lateral fusion codes
•    Removal of old instrumentation and insertion of new instrumentation in revision surgeries.
•    Use of bone marrow aspirates with other procedures


Insurance companies will deny claims when procedures are unbundled, which can be devastating for spine practices, especially when they are unaware of the change.


More Articles on Spine Surgeons:
Spinal Revision Surgery: Why Patient Expectations Matter
The Future of Spine Surgery: Pervasive Scrutiny & Shifting Trends Create Uncertainty for Inpatient Spine Procedures
Spine Moneyball: How Analytics Will Impact Spine Care Over the Next 5 Years

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