Expecting to get paid for every step of surgery and for hospitals and health systems to always aim to maximize surgical reimbursement are two misconceptions spine surgeons need to be aware of.
These two spine surgeons recently connected with Becker’s to discuss the biggest misjudgements related to reimbursements.
Editor’s note: Responses have been lightly edited for clarity and length.
Question: What is the biggest misconception surrounding spine reimbursement?
Alpesh Patel, MD. Co-director of Spine Surgery of Northwestern Memorial Hospital (Chicago): This may be specific to employed spine surgeons, especially those without experience in private or profit-and-loss models. The most common misconception amongst these surgeons is that their hospital or large consolidated employer is aligned with maximizing surgical reimbursement. They may find that that employer is more concerned about other metrics that, to the contrary, conflict with maximizing surgical reimbursement. For example, a large employer may be more concerned with the potential for litigation from overbilling and may therefore choose to undercode. This would benefit the hospital’s compliance but directly harm surgeon reimbursement. Another example would be a business decision to incentivize surgical coders based on accuracy of submitted codes. This creates an unintended consequence of submitting fewer codes so as to avoid denials. There are many more examples where hospital/employer goals and incentives are not aligned with spine surgeons. Surgeons in these situations should understand the potential for misalignment and be proactive.
Ashish Sahai, MD. Orthopedic Spine Surgeon at Spine & Orthopedic Center (Boca Raton, Fla.): One of the biggest misconceptions in spine reimbursement is that you’ll actually get paid for everything that you’re doing in surgery. During the pre-op process, you almost have to lay out a pre-surgical report to incorporate everything; otherwise, it will be denied when it comes time to get reimbursed. Then you’ll have to fight to get paid, and the delays will affect cash flow and revenue management. You have to walk a fine balance for this.
