Spine surgery coverage denials cost surgeons $191k: 5 key notes

Written by Laura Dyrda | April 27, 2016 | Print  |

The International Society for the Advancement of Spine Surgery released results from a study about how a third-party payer's delay or preauthorization coverage denial can impact spine practices.

ISASS sent a 14-question survey to 571 spine surgeons about their perceptions of third party payers' delay or denial for preauthorization coverage and payment. There were 115 surgeons who responded with an annual case volume ranging from 50 cases to 700 cases; the average was 300 cases.

 

More than half — 51 percent — of the cases were lumbar surgeries; 35.9 percent were cervical surgeries. Most of the respondents were orthopedic spine surgeons — 67 percent — while the remaining were neurosurgeons.

 

Here are five key findings from the survey:

 

1. A majority — 84.3 percent-said insurance denials led to unfilled operating room time. By comparison, 11.8 percent reported patient medical issues and 10.8 percent reported office/hospital inefficiencies as the culprit for unfilled OR time.

 

2. Around one-fourth of the cases were denied during the preauthorization process, but 58.5 percent of the cases were denied three days or fewer before surgery.

 

3. Of the denials, 72.7 percent reported lumbar spine surgery denials; 21.4 percent reported cervical spine surgery denials.

 

4. Around 24 percent of the cases yielded reduced payments despite preauthorizations; another 9.4 percent weren't paid despite the preauthorization.

 

5. The calculated total potential in lost revenue was $191,250 based on Medicare reimbursement for instrumented and non-instrumented cases. The researchers calculated the total potential lost revenue for physicians with average 300 case volume and the 25 percent denial rate, equaling 75 lost cases.

 

"Surgeon perceptions of insurance and pre-authorization delays and denials have a significant negative impact on surgical scheduling and the efficient utilization of OR block time," concluded the study authors. "Further, respondents indicated surgery preauthorization does not lead to appropriate reimbursement in approximately one-third of the cases."

 

More articles on spine surgery:
5 key notes on revision spinal surgery for recurrent lumbar disc herniation
5 things to know on osteoporosis for cervical spine surgery patients
Novel technologies make a splash in outpatient spine setting—Dr. Nick Shamie weighs in

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