2 spine surgeons discuss current payer challenges and how they're navigating them


Two spine surgeons outline payer issues that they recently experienced and how they are dealing with them.

Ask Spine Surgeons is a weekly series of questions posed to spine surgeons around the country about clinical, business and policy issues affecting spine care. We invite all spine surgeon and specialist responses.

Next week's question: How do you see AR and VR impacting spine care? What potential innovations excite you in this space?

Please send responses to Alan Condon at acondon@beckershealthcare.com by 5 p.m. CDT Wednesday, April 15.

Note: The following responses were lightly edited for style and clarity.

Question: What was your most recent payer struggle? How did you navigate it?

John Koerner, MD. Rothman Orthopaedic Institute (Philadelphia): One of the recent struggles from the COVID-19 crisis was figuring out how to see patients for telemedicine visits at Rothman Orthopaedics, and then how to get reimbursed for it. Without integrated video capability, what needed to be documented to bill for a certain level of visit? At first, the most important thing was to be in contact with all patients scheduled for office visits, document as much as possible and worry about the billing later. 

CMS has at least temporarily eased some of the requirements so telemedicine visits can be done over the phone, and the place of service is reported as if the visit was in the office. The American Academy of Orthopaedic Surgeons has regularly updated policies regarding COVID-19, which includes information on CMS updates and many commercial health plans. The duration for which these policies will remain in effect vary by plan and requirements for billing a telemedicine visit is likely to change over time as well. Some worker's compensation carriers have required authorization for telemedicine visits on a case by case basis. These policies on telehealth are temporary, so it is important to follow the updates as they come.

Brian Gantwerker, MD. Craniospinal Center of Los Angeles: The latest turn of the screw is the authorization 'take back.' A recent patient of mine needed an anterior lumbar fusion. This a straightforward and very successful surgery in most hands, including mine. I spoke with an insurance peer reviewer, who authorized the surgery verbally. The insurance company then wrote me and the patient a letter — they overrode their own surgeon reviewer. The patient got his surgery and he had to pay for it. So, he is in the process of suing the insurance company and I am planning on bringing his case before some members of Congress. 

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