The way spine surgeons manage their cases has been largely shaped by one persistent hurdle: prior authorization.
The extra steps that come with prior authorizations and potential denials have made spine surgeons more nimble to get ahead of them. From homing in on documentation to creating spine-specific checklists, five surgeons discuss their strategies.
Editor’s note: Responses have been lightly edited for clarity and length.
Question: Prior authorization denials in spine and orthopedics continue to be a flashpoint. Have you changed how you practice specifically because of these obstacles? How has it affected your margins, long-term goals, etc.?
Jeffrey Carlson, MD. Orthopaedic & Spine Center (Newport News, Va.): Prior authorizations have been a stopping point for a significant number of patients. We have seen insurance companies use PA to inhibit the continued care of patients through their healthcare journey. This barrier will cause patients to fall out of treatment and continue to suffer the consequences of their diseases. PA has become a constant with many surgeries, advanced imaging and invasive treatments. The most frustrating aspect is the lack of diligence done by the insurance company. After denying a treatment, requiring PA, our office sends the required information to get the authorization, which leads to a peer-to-peer discussion. This discussion is often preambled by the insurance physician saying he didn’t get the information that was sent supporting the treatment. This becomes a waste of time for the treating physician, insurance physician and ultimately the patient. You wonder why the insurance physician set up the call if he didn’t have the clinical information to make a judgement. We have started to check for assurances that the insurance physician has received and reviewed the clinical information prior to taking the next step, and have found many times the PA was approved before there was a need for a peer-to-peer discussion scheduled.
Peter McCunniff, MD. Arizona Spine and Pain (Phoenix): Last-minute denials and peer-to-peers are extremely disruptive to all providers and orthopedics and spine, and likely disproportionately so in spine surgery due to the heterogeneity of the case types and longer OR duration that makes it incredibly difficult to backfill these spots in the event of a late cancellation. Depending on what data you look at, the true cost of a late cancellation from last-minute denials is somewhere between $10,000 to $20,000 for an ASC and even higher for more complex, inpatient hospital cases.
The highest-yield initial steps that a surgeon and their team can take to drastically cut down on the number of preventable cancellations really comes down to timing and documentation. When submitting authorization for spine surgeries, these need to be sent out in the first 48 to 72 hours after the decision for surgery is made in order to give you the maximum amount of buffer time to deal with some of the nonsensical discrepancies that seem to result in denials requiring resubmission or further action like [peer-to-peer].
The next measure we have taken is to develop a universal spine surgery prior authorization checklist for my surgery schedulers who are going to be submitting for authorization which has all of the necessary components in order to avoid the vast majority of denials. Crucial components here are documentation of physical therapy notes and other nonoperative modalities, as well as procedure notes from epidural steroid injections or selective nerve root blocks. Payers are no longer excepting simple statements from surgeons describing completion of conservative measures and instead are requiring the visit notes and procedure notes from the physical therapy and interventional pain providers which can require extra effort on your team’s part.
Once you have the systems in place to make this process standard and reproducible for your team then you will see significantly less chaos in the 48 hours leading up to surgeries and huge dividends for your practice and your patients.
Brandon Ortega, MD. Long Beach (Calif.) Lakewood Orthopaedic Institute: Prior authorization has forced real, structural changes in how I manage my practice. I specialize in motion preservation surgery, cervical and lumbar disc replacement, and these are among the procedures most likely to face unnecessary scrutiny, especially for hybrid cases. The result is that we’ve had to dedicate meaningful staff resources to authorization management that should be going toward patient care.
On margins, the damage isn’t always a clean denial you can point to. More often it’s attrition, delayed cases, peer-to-peer calls that consume physician time, appeals cycles that stretch weeks. Multiply that across a high-volume practice and the drag becomes significant.
Strategically, I think prior auth pressure is one of the underappreciated drivers of the migration toward ambulatory surgery centers. Surgeons are seeking environments where they have more control over scheduling and case flow, and less exposure to payer-side administrative friction. That’s not a coincidence, it’s a rational response.
The reform I’d most want to see is specialty-matched clinical reviewers and enforceable turnaround timelines. A general physician reviewing a multilevel disc replacement case isn’t equipped to make that call, and the current system doesn’t require them to be. Until that changes, the burden falls disproportionately on surgeons and their patients.
Rajiv Sethi, MD, PhD. UCSF Health: Prior authorization denials in spine and orthopaedics remain a vexing challenge for surgeons and most importantly those that we serve: our patients. In spine, it remains important that our best universities support important health services research that highlight the efficacy of select spinal interventions delivered in a timely fashion underscoring the importance of payor adherence to published findings. At UCSF, we aim to do this by studying value-based care processes in musculoskeletal health care delivery. Long-term goals must include the reduction of prior authorization delays for ethical and evidence-based interventions that give our patients better function and satisfaction.
Robert Tatsumi, MD. President of Oregon Spine Care (Tualatin): I have found that commercial payors have similar clinical guidelines for surgical indications for spine surgery.
Ensuring the patient meets these clinical guidelines and communicating these findings into the electronic medical record via templates successfully limits denials. When I receive a denial and request a peer-to-peer conference, the denial is typically overturned after the medical doctor reviews my note, before my phone call.
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