Becker's ASC Review

14 ORTHOPEDICS 'No other industry would tolerate this': The problem with prior authorization in spine surgery By Claire Wallace e prior authorization system is seen as flawed by many surgeons working in orthopedics, spine surgery and beyond. It oen slows down patient care, adds administrative tasks for employees and sometimes even leaves physicians to foot the bill for expensive patient procedures. ree neurosurgeons, Anthony DiGiorgio, DO, Praveen Mummaneni, MD, and Luis Tumialan, MD, issued a statement to Becker's explaining the major problems physicians face when it comes to receiving fair payments for services offered. "Consider the following two scenarios: Imagine a broken pipe is causing a flood at your home. Your next steps are to contact your insurance carrier, open up a claim and then find a contractor to assess and repair the damage. e contractor provides your insurance company with a bid for the proposed work, which the insurance company reviews and approves. Upon completion of the work, the contractor submits for payment. e insurance company pays the claim. "Now imagine you have a grade 1 L4-5 spondylolisthesis. Aer years of nonoperative treatment, you see a surgeon who recommends surgery. e surgeon completes a prior authorization of the proposed procedure which your health insurance carrier approves with the caveat, 'prior authorization is no guarantee of payment.' e surgeon performs the procedure as stated with great results. You are genuinely surprised to find out at a post-op appointment that your insurance carrier denied your surgeon payment. "e surgeon's business office then begins the process of filing appeal aer appeal over the next several months and ultimately writes off the balance. us, the surgeon performed the surgery for free on someone with commercial insurance. e first house flood scenario is how the real world works. e second scenario happens in 1 out of 10 spine surgeries. Denial of payment aer prior authorization has become a grim reality of American healthcare. "As bewildering as it may sound, insurance companies authorize procedures. Surgeons perform them as authorized. But then, the insurance company denies payment. No other industry functions in this manner. No other industry would tolerate this system. Yet, in healthcare, physicians, bound by their oaths to care for patients, endure a system that withholds payment. Surgeons put up with prior authorization, payment delays and overwhelming administrative tasks. "Why even maintain a prior authorization system if it serves as nothing more than a mirage? Is it a placebo for surgeons? e prior authorization lulls the surgeon into a fabricated sense of security that they will receive payment for their services. Ultimately, patients bear the brunt of this charade. When insurance companies do not uphold their end of the bargain, surgeons face limited options. Many will not bill patients directly, refusing to fault individuals whose only misstep was choosing an unreliable insurance carrier. "Patients have the right to a top-tier health system where they can select their surgeon. ey deserve insurance companies that uphold their contractual promises. e transactions between surgeons and commercial insurers should be no different than a contractor and home insurance carrier. Work completed must result in work paid. It is high time insurance companies fulfilled their contractual obligations just like every other industry." n Are insurance companies determining the future of orthopedics? By Claire Wallace A s the orthopedic industry continues to innovate with new robotic, 3D-printed and GPS-guided navigation options, physicians are concerned that insurance companies won't be open to covering new care options. Potential care plan denials by insurers often result in patient care delays and revenue delays for orthopedic surgeons. Additionally, as orthopedic and spine procedures expand into the ASC setting, payers are increasingly resistant to covering certain procedures in an outpatient setting. While new technologies provide great options for patients, and ASCs provide ideal orthopedic surgical environments for many, the industry won't be able to see benefits if insurers choose to continually deny coverage for these care options. Michael Redler, MD, a surgeon at Connecticut Orthopedics in Hamden, told Becker's that the future of many techniques will rely on the payers. "Orthopedic surgery is a specialty whereby technology is changing at an ever-increasing rapid pace. There are so many new options for treating patients that didn't exist 10 years ago. The big challenge for orthopedic surgeons today is balancing the role of new technology in an environment where cost savings are going to continue to be very important. Many of these outstanding technologies can be used in an ASC-type setting. The challenge, of course, is getting the insurance companies to agree to pay for these technologies when performed in an ambulatory setting. This not only relates to implants and new techniques, but also to the always important perioperative comfort experience. Our ability to perform opioid-sparing surgery is going to, in part, rely on the insurance companies recognizing the importance of the great advancements that have been made in minimizing the need for narcotics. Insurance companies' acceptance of new injections and devices to minimize opioid use will not only benefit the patient, but society as a whole." n

• Cover