The biggest challenges in spine reimbursement today and the value-based solution

Written by Laura Dyrda | September 19, 2018 | Print  |

Jim Sanfilippo, MD, is a spine surgeon at Reconstructive Orthopedics in Marlton, N.J.

A New Jersey native, Dr. Sanfilippo joined Reconstructive Orthopedics in 2009 and serves as the chief of the spine section as well as chair of the Virtua Brain and Spine Institute and medical director of the musculoskeletal service line at Virtua Memorial Hospital in Mount Holly, N.J.

Dr. Sanfilippo is a featured speaker at the Becker's 17th Annual Future of Spine + The Spine, Orthopedic and Pain Management-Driven ASC Conference, June 13-15 in Chicago. Click here to learn more and register. For more information about exhibitor and sponsor opportunities, contact Maura Jodoin at

Here, Dr. Sanfilippo discusses the biggest opportunities in spine and how surgeons are evolving their practices to meet value-based care requirements.

Question: What are the biggest reimbursement challenges for you today? What is the payer landscape like for your practice?

Dr. Jim Sanfilippo: We are an in-network provider and on-par with most major payers in our area. With that said, one of our biggest challenges with regard to reimbursement surrounds third party authorization companies. Some of the payers in our area have subcontracted out their pre-authorization process. These companies tend to have indications for surgical procedure that differ from our commonly accepted standards of care and generally agreed upon indications, leading to unnecessary denials and time-consuming preoperative appeals with their medical directors. But even in the cases that get "approved" we often find out that the authorization numbers were never sent to the payer and we get denials after the procedures have been performed. This often leads to a drawn-out appeals process and delay in payment.

Q: Where do you see the biggest opportunity for bundled payments and other risk-based contracts? Have you considered them for your practice?

JS: As a group, we have entered both bundle payment arrangements that have no downside risk, as well as those with risk sharing. The biggest opportunities for bundled payments and other risk-based alternative payment programs revolve around patient navigation, moving cases to the appropriate site and level of care including hospital outpatient and ASCs, and in partnering with our healthcare systems to streamline our delivery and eliminate unnecessary pre- and postoperative testing and treatments.

With patient navigation we can intervene at the necessary times to help prevent urgent care and ER visits, help drive down readmissions, promote overall compliance following surgery and limit the number of patients needing to go to expensive inpatient rehab facilities. By moving patients to the appropriate level of care, as well as eliminating unnecessary testing and treatments, we can drive down the cost associated with the procedure.

However, my biggest concern is this "race to the bottom" with target pricing being adjusted down with each new contract. Eventually, there will be no more water to squeeze from this stone.

Q: What changes have you made or are you considering for your practice as healthcare moves toward value-based reimbursement and care delivery?

JS: Our practice has been collecting our postoperative quality metrics for over five years now. Recently we began to introduce electronic patient navigation for both our pre- and postoperative patients. We have also hired nurse navigators to assist in this process, with their primary role to ensure compliance of our patients in answering our online surveys, ensuring patient education is reviewed and responding to any patient concerns or survey answers which may indicate an issue with a patient.

We have also begun discussions with our hospital partners around the delivery of health services, both while an inpatient and in the postoperative period. These include services such as lab testing, imaging, PT, home health, etc.

In addition, our new ASC, opening in February of 2019, will include overnight beds, allowing us to offer procedures, which may require an overnight stay for recovery, in the ambulatory setting.

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