Insurance denials are a common hurdle for spine surgeons, and these often stem from peer-to-peer reviewer decisions.
Two spine surgeon leaders shared their perspective on the peer-to-peer review process with Becker’s.
Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: Ask your patient if they would be willing to jump on the call with the peer to peer reviewer. That way if they decline it, the patient can ask why. Then ask the reviewer to provide their NPI number and their name and credentials. In light of the death of the UnitedHealthcare CEO, some people on the phone call are unwilling to provide their credentials, which gives the unseen effect of essentially giving them over not to answer. However, we’re still asking them to provide those things.
We think it’s a reasonable ask. They don’t have to give us their last name, but just their NPI. They can provide that, and if they don’t, you really don’t have much recourse. But the best way, I would say, is to have the patients on the phone with you and have them ask the reviewer why they will not allow us to do their procedure.
Bethwel Raore, MD. Apex Spine & Neurosurgery (Bethlehem, Ga.): I think that a lot of changes need to be made in this process. For instance the insurance company can deny care without repercussions. One of the worst players … regarding their role are the physicians and the nurses who work for the insurance companies. These are the people who took the Hippocratic oath to take care of the patient, but they will deny them coverage. They will deny imaging. They will deny medication that the patient wants to get, or that their physician has recommended, but they absolutely have no responsibility when this disease progresses. Then when there’s a death, they have no malpractice exposure in all of this. This is ridiculous. The insurance companies are able to achieve what they’re achieving because other physicians and other nurses and healthcare providers are participating.
I’ll just finish with this one situation where a middle-aged female who’s pretty active in her community has some back pain. At some point the primary care provider orders an MRI and that’s been denied. They say, go to physical therapy, and she’s going to therapy, and the MRI request is denied again. The circus of MRI denial goes for about five to six months, and by the time I am seeing the patient she has a foot drop. When we got the MRI through the emergency room, she had metastatic cancer destroying the sacral and L5 vertebral body.
When you dig further you’re thinking, “What could have happened six months ago when this should have been found?” Could it have been avoided? Yes. This brings the whole picture of what we are seeing right now. This issue deserves a conversation, which it is now getting.
