Physicians and practice leaders increasingly point to payers as one of the biggest obstacles to running a sustainable practice. From CMS policy changes and declining Medicare reimbursement to private payer prior authorization requirements and coverage denials, administrative and financial strain continues to mount for spine and orthopedic groups.
Becker’s connected with six spine and orthopedic surgeons and leaders to ask about their most frustrating payer problems and how they are responding.
A common thread emerged: Getting care approved is only half the battle. Several respondents said prior authorization delays care and drains staff time, often based on guidelines that conflict with accepted clinical practice and decisions made by reviewers who have never examined the patient. Even after surgery is authorized and performed, they said payers frequently deny claims, request records that are then reported as missing, or claw back payments after the fact. Others pointed to underpayment, delayed reimbursement and rates that have not kept pace with rising practice costs, along with concerns about payer consolidation.
In response, some practices are turning to AI-driven revenue cycle tools and centralized authorization tracking, while others are opting out of Medicare, investing in their own facilities or offering private-pay options to reduce their dependence on traditional insurance.
Question: What’s the most frequent or frustrating payer problem you’re dealing with right now, and how are you addressing it?
Editor’s note: Responses have been lightly edited for clarity and length.
Lou Amorosa, MD. Orthopedic Spine and Trauma Surgeon of Ridgewood (N.J.) Orthopedic Group: Increasingly more spine surgeons are opting out of Medicare and Medicare Advantage programs. This is understandable given declining reimbursement and the prior authorization game for oftentimes complex but indicated surgeries in a generally higher risk patient population. On an individual level as a physician, it presents an ethical dilemma to decide not to treat more vulnerable people for economic reasons. On a macro level, it bodes poorly for society when older people lose easy and timely access to high-quality care.
Eric Cohen, MD. Orthopedic Surgeon of University Orthopedics (East Providence, R.I.): Our most frustrating challenge is payer underpayment and delayed reimbursement. In a high-volume setting, tracking small contractual variances manually is nearly impossible, meaning revenue easily slips through the cracks. We now leverage AI-driven revenue cycle tools to automatically flag these discrepancies, giving our billing team the precise data they need to efficiently follow up, demand accurate payouts, and protect our bottom line.
Brandon Hirsch, MD. Orthopedic Spine Surgeon of DISC Sports and Spine Center (Newport Beach, Calif.): The most frequent and frustrating payer problem I deal with is the use of tactics to deny responsibility for payment for unquestionably indicated surgery, either during the preauthorization process or after an authorized surgery has been completed. These tactics are not new, but they have become so pervasive and egregious that I would not be surprised if employers move away from traditional health insurance altogether. Patients and their employers are simply not getting what they paid for, and this shows in the quarterly profit statements of the major insurers.
On the preauthorization side, payers employ medical benefits management or utilization review companies to determine whether a physician’s plan of care is medically necessary. These companies, working with the insurers, create treatment guidelines that often conflict with commonly accepted clinical practices in spine surgery and with the best interest of the patient. Certain organizations are even going so far as to dictate the surgical technique that is medically necessary for certain disc herniations based on their location in the spine, and they employ physician reviewers who defer to their employers’ guidelines rather than using their own clinical judgment.
After a preauthorized surgery has been completed, payers often deny the claim first and request medical records to support the necessity of the procedure. Those records are sent, and the claim remains in denial status. When billers call to check on the claim, they are often told the records have not been received, despite their having been uploaded to a payer portal that is visible to anyone with access. This delays payment further and leaves many surgeons wondering whether it is worthwhile to contract with these payers in the first place, and many of my colleagues are moving to alternative models outside of traditional insurance. In my view, these difficulties will continue and will ultimately move Americans toward direct pay models, which already work with great success in primary care, offering price transparency, minimal obstacles to receiving care, and overall, a more satisfied patient and a more effective physician.
Farzin Kabaei, MD. Orthopedic Trauma and Joint Reconstruction Surgeon of DOCS Health (Los Angeles): My biggest payer problem right now is the PPO plans. Patients buy a PPO because they were told it gives them choice. Then they need surgery and find out how little that choice is worth.
It starts with prior authorization. A patient who cannot walk waits on an approval for surgery, imaging or an implant, and the decision often comes from someone who has never examined them. Every delay is more pain for the patient and more unpaid staff time for the practice.
Then comes payment. PPO rates have not kept up with what it costs to do a hip or knee replacement well, and the check often arrives late. My staff, my rent and my implant costs do not run on the insurer’s schedule.
The third piece is out-of-network benefits. Patients pay higher premiums for a plan that is supposed to let them see the surgeon they want. When they try to use that benefit, the coverage turns out to be far thinner than they were led to believe. They are surprised, and the surgeon is the one who has to explain it.
How am I addressing it? Two ways. First, we own where we operate. At DOCS Health, our group owns its surgery center, and we are building a second one and our own hospital. When you control the facility, you control cost, quality and scheduling, and you are less dependent on what a payer decides. Second, I offer patients a private-pay option. The price is clear up front, there is no authorization to wait for, and the decision about surgery stays between the patient and the surgeon. More patients are choosing it than I would have expected a few years ago.
None of this fixes the PPO problem. It just keeps an independent practice standing while the plans keep moving the goal posts.
Emeka Nwodim, MD. Orthopedic Spine Surgeon of The Centers for Advanced Orthopaedics’ Bay Area Orthopaedics & Sports Medicine (Hanover, Md.): The most disappointing payer problem I believe is a combination of excessive administrative burden for prior auths, compounded by clawbacks. The idea that a prior auth can be obtained yet a payer can decide to later deny the claim and retrieve funds is ridiculous and should be unacceptable in our society.
Joshua Smith, COO of Fondren Orthopedic Group (Houston):
One of our biggest frustrations is how much work it takes to get care approved and then get paid after we’ve provided it. Prior authorizations, denials and downcoding take time away from supporting patients. We spend significant time, energy, and money chasing payments for care already delivered.
For independent practices, that comes on top of rising staffing, technology, supply and facility costs. Medicare physician reimbursement hasn’t kept pace with practice-cost inflation over the last decade. We’re paying more to deliver care while also spending more to collect payment for it.
Payer consolidation adds another challenge. When an insurance company also owns physician practices, pharmacy benefit managers and pharmacies, independent groups can find themselves competing with the same organization they’re trying to partner with on patient care. That raises real concerns about bargaining power, patient choice, and the future of independent practice.
At Fondren Orthopedic Group, we’re standardizing workflows, centralizing authorization tracking, integrating AI where appropriate and making responsibilities clearer so we can submit complete requests and catch delays earlier. Those changes help, but payer-specific requirements still mean repeated follow-up and uncertainty for patients and payment for care, especially around surgery and advanced imaging.
We can improve our processes, but we also need payers to simplify theirs. Getting appropriate care approved and properly documented services paid shouldn’t require this much back-and-forth.
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