1. Payer’s coverage criteria and guidelines are changing. Payers are using a different set of guidelines for covering spine surgery; many are based on variations of the Milliman guidelines. Some surgeons argue that the Milliman guidelines, now known as MCG, are inappropriate because they are based on outdated studies and written by non-medical professionals. Regardless of the source, surgeons should know the payer’s guidelines and have an understating of how they can ensure coverage in the future.
“You really need to have an understanding of the criteria for coverage so you know why they are sending denials,” said Jeffrey A. Goldstein, MD, director of the spine service and director of the spine fellowship at NYU Langone Medical Center’s Hospital for Joint Diseases. Dr. Goldstein is also a board member of the International Society for the Advancement of Spine Surgery. “If they say it’s based on Milliman criteria, you should have a copy of that. Insurance companies or professional societies should be able to provide you with these guidelines.”
This is especially true for lumbar fusions. “Milliman guidelines that drive insurance company policies continue to become stricter in their criteria for approval for lumbar spine fusion surgeries,” Dr. Goldstein said. “It’s important to know exactly what each insurance company requires before submitting for pre-authorization.”
2. Coding for new technologies is more challenging. Coding for new technologies can be a challenge because they don’t have an assigned code; instead, coders use unlisted codes. T-codes and unlisted codes can throw up red flags for authorization of procedures and are difficult for many centers to achieve coverage.
“Spine and orthopedic surgery are expanding technology every day and we want to be able to provide access to those technologies for our patients when it is appropriate,” said Carolyn Neumann, CPC, senior manager or coding & Coverage access at Specialty Healthcare Advisers, a subsidiary of Musculoskeletal Clinical Regulatory Advisers. “There is a process for receiving reimbursement on these codes that although time consuming, it’s possible to be reimbursed on the facility and physician side. Prior authorization is essential when you are using these codes and it takes great physician commitment to go through the appeals process so the procedures are accurately reimbursed.”
When coding with unlisted and T-codes, Ms. Neumann suggests including any common procedures reported with T codes in payer contracts and knowing the code description in side and out.
3. Payers are demanding more documentation. Spine surgeons across the country are hearing they need more documentation from each case before payers will approve surgery. Sometimes surgeons can predict the type of documentation they will need, such as proof the patient took the appropriate pathway of physical therapy and epidural injections before deciding upon surgery; other times, the missing documentation isn’t quite as clear.
“Sometimes when you are asking for approval on the big ticket items, payers aren’t very straight forward about what you need in your documentation,” said Christopher Kauffman, MD, a spine surgeon in Nashville, Tenn., and chair of the North American Spine Society’s Professional Economic and Regulatory Committee. “You can tell them how long the patient has been having problems and show them they’ve been through the treatment pathway, but the payer will still deny surgery because you don’t meet all the requirements, but they won’t tell you what the requirements are. I can’t do a good service for my patients if I can’t answer these questions.”
Gathering all the documentation necessary can be challenging for spine surgeons, especially when patients have their non-operative care elsewhere.
“Often, the primary care physician has overseen the non-operative care and we may not have put all the medications, physical therapy and ESIs performed in our notes,” said Dr. Kauffman. “The insurer sees that this is the patient’s first visit to the surgeon, so they assume the patient hasn’t done anything else and isn’t a candidate for surgery.”
4. Secondary procedures are getting a zero. Commercial insurance companies often contract to reimburse spine surgeries with primary codes paid at 100 percent and secondary and tertiary procedures at 50 percent of the fee schedule rates. However, with new edits, some insurance companies bundle services and take a zero on the secondary procedure. This can be devastating for spine surgeons and practices.
“They set billing edits to bundle secondary procedures, so these managed care and commercial payers are using edits that contradict their contracts,” said Danielle Koelbl, president of MedRev Solutions. “Those secondary procedures are getting a zero because of the edits. It’s something that’s happening a lot. Providers have been told to appeal these cases and provide the contract language, but you have to develop a relationship with payers to really solve the problem.”
Leverage this relationship with payers to get the edits removed because if you don’t, you stand to lose a sizable amount of revenue.
“Insurance companies sometimes change their edits and it doesn’t come up with the providers until they get a denial,” said Kendra McKinley, president of Doctor’s Billing, Inc. “They reduce procedure codes with mass payment. They are reducing procedure codes that are exempt from the reductions. Having the specific contract language in the contract is so important. Spine surgery can be scheduled so far in advance that something could go out of coverage and providers aren’t even aware.”
Stay updated on payer contracts and coverage guidelines; otherwise you may find a previously covered service no longer covered when the denial comes.
5. Spine surgeries are being retroactively denied. In some cases, even after the surgery is approved and performed, insurance companies can retroactively deny the procedure because their policies have changed.
“What happens is the CPT codes are submitted [for outpatient procedures] and then the insurance companies decide they don’t like the code or have a question, so instead of paying for it they kick out the whole claim and deny payment,” said Marc Cohen, MD, a spine surgeon based in New Jersey. “All of a sudden they’ve done a review with some physician and decided retrospectively that the patient didn’t need the surgery so they will deny payment.”
In these situations, the surgeon has run out of options for payment on the retroactively denied claim; however, surgeons still have the ability to exert more control over future claims situations.
“The only thing surgeons can do is be more proactive to gain back control of the system,” he said. “Try to be more proactive to get a handle on the future. The only way we can do this is getting back to the fact that we must show data and outcomes proving we provide a legitimate service and that our procedures are good, safe and cost-effective.”
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