Prior authorization can be a pain point for spine surgeons getting reimbursement approved by CMS and insurers, but artificial intelligence holds potential for improving that process for providers, Brian Gantwerker, MD, said.
Dr. Gantwerker, of the Craniospinal Center of Los Angeles, spoke with Becker’s about three ways AI can help.
Note: This conversation was edited for clarity and length.
Question: What healthcare policies have you been following lately?
Dr. Brian Gantwerker: There’s the Wasteful and Inappropriate Service Reduction policy. For some of us, it’s very concerning. I understand because it involves artificial intelligence dictating outcomes of prior authorization. Some are worried about physicians not being involved in the process and only the arbitration part. I understand that, but AI is here, and I’ve talked about how much I don’t like it. But I will say AI is an opportunity for a few things.
If AI is used for prior authorization, then if the procedure will be deemed medically necessary by their own software, any reasonable person can say that if it’s authorized. It’s an opportunity to hold insurers to account if they’re going to use software that they themselves buy and employ. If their software says a surgery is medically necessary, then physicians should get paid. Insurers will be essentially arguing with themselves if they don’t.
The second thing is the CMS Gold Card where if you have a certain number of authorizations, you don’t have to get prior authorizations for a year, which I think is a great idea. I know that folks down in Texas are doing it. Part of the deal of doing prior authorization is we should be able to get Gold Card maybe for a year, maybe even two because if we’re doing the right thing and their own software and in-house physicians look at it, then it should be a non issue.
The third thing is clawbacks. If you have a prior authorization being run by an algorithm, you’ve given the algorithm for the CPT codes you’re going to use, and you turn in a claim with those with those codes, and the number that you’re going to get from the insurer is baked into that, then the insurer should have no reason to try to claw back money. You submitted a clean claim with the codes that you said you were going to use, the documentation supports it.
