5 Spine Surgeons on Responding to Coverage Denials

Written by Laura Dyrda | March 13, 2012 | Print  |
Here are five spine surgeons discussing how they approach conversations with payors about coverage denials. 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 is: Where could you reasonably expand your practice for ancillary income?

Please send responses to Laura Miller at laura@beckershealthcare.com by Monday, March 19 at 5pm CST.

Q: How do you approach conversations with payors about coverage denials?

Ara Deukmedjian, MD, Founder, Deuk Spine Institute, Melbourne, Fla.:
We inform the patient immediately and get them involved in the dialogue with the payor as soon as possible. Patients deserve to know the truth and we want to let them know that their care is being denied by their insurer and not our practice. If the patient is motivated to get treatment they will usually be our best ally in dealing with the insurer. I believe it is time physicians let the public in on the "truth" about insurers. I pity the insurers the day the American people become aware how much of their healthcare has been stolen from them by the insurance industry and at what cost. Americans pay more now for their health insurance than ever before and yet receive less covered benefits in return and not for lack of want or need.

Every day insurers are adding more treatments and tests to their list of denied or non-covered services even though those services are considered by doctors as medically necessary for the patient’s wellbeing. In my experience, denials happen 95 percent of the time for only one reason: for the insurer to keep more money for themselves and bolster their profits. Denials do not improve patient care and their purpose is really just a legally sanctioned way of diverting money away from patient care and into the pockets of insurers who are now posting record quarterly profits while there are growing numbers of Americans without coverage for tests, medications or treatments their doctor prescribed. Doctors cannot bring about the changes needed in insurance reform alone and ultimately overturning an insurer’s ability to deny patients medically necessary treatment will only happen if every American stands up to the insurers together and we say, "Enough is enough. Get out of my doctor-patient relationship!!"

Walter Eckman, MD, Founder, Aurora Spine Center, Tupelu, Miss.:
Mostly done by experienced nurse. She is extensively trained in coding and has lengthy experience which brings credibility to her conversations. It is very helpful to have nine years of experience in keeping outcome studies. When the insurance companies know patients are going home the same day and they receive information about our excellent outcomes and our selection concepts for surgery (for example most of our lumbar fusions are one level) we generally have little difficulty with these issues.

J. Brian Gill, MD, Spine Surgeon, Nebraska Spine Center, Omaha:
I always request a peer to peer review to understand why a surgery was denied, as well as understand how I can prevent them in the future. Each insurer is a little different in approaching denials, which is why I request a peer-to-peer review. I have had several surgeries approved through the peer to peer review process.

Khawar Siddique, MD, Spine Surgeon, Beverly Hills Spine Surgery, Calif.:
Be aggressive! Some physician reviewers have conflict of interest and need to know that we will fight for the best interest of the patient.

Paul Slosar, MD, President, SpineCare Medical Group, San Francisco Spine Institute:
I first approach peer review calls with politeness and try to give them as much information as possible. If we get a denial I usually write a very direct and specific letter about the case, also adding some information about my credentials as well. There are very few doctors doing these reviews who are as well published or credentialed as I am, and if they are interfering with my care of a patient, I don't hesitate to point that out. I also tell the patients to get involved and call the medical director.  If all else fails, I send the case out to the Spine Care Alliance (www.spinecarealliance.org), as they specialize in getting denials approved.

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