Becker's ASC Review

14 ORTHOPEDICS 2 tips for spine surgeon, payer conversations in 2025 By Carly Behm A continuing pain point for spine and orthopedic surgeons is prior authorizations and working with payers to get patients' care covered. Brian Gantwerker, MD, of e Craniospinal Center of Los Angeles discusses the way physicians should approach payer conversations and what he wants to see from physician peer reviewers. Note: is conversation was lightly edited for clarity and length. Question: What advice do you have for spine and orthopedic surgeons to manage negotiations in 2025? Dr. Brian Gantwerker: First ask your patient if they would be willing to jump on the call with the peer to peer reviewer. at way if they decline it, the patient can ask why. Number two, ask the reviewer is, 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. ey don't have to give us their last name, but just their NPI. ey 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. Q: Have you been able to get any of your own patients on a call like this? BG: I have not been able to get a patient to hop on with me due to scheduling issues. Usually the payers will provide a very inconvenient time to schedule the call, and the patient may be at work or may be taking care of a sick family member or they may be incapacitated. It's a hard thing to thread that needle, but if you are somebody who has to get a lot of prior authorizations, it is something worth trying to involve patients. Any reasonable person who's paying for insurance has a reasonable expectation that the payer will pay for their care if it's medically indicated. We're the physician on the call and the reviewer on the other line is a physician but insists that they are not part of the care team, but they're making medical decisions. It seems any reasonable person would say that reviewers bear some responsibility in the patient's healthcare there because they're making medical decisions. I'm not saying to throw out the prior authorization altogether. I think overall it's a necessary evil, but we all have to play by the same set of rules. If a patient, for example, has a large disc herniation and a neurologic deficit referable to that, surgery is indicated. I think any person would look at that case and say that the operation needs to be done. What we need from our physician reviewers, our partners and physician reviewers, is that they have to essentially override whatever the insurance company tells them and just step back into being a doctor. You took a Hippocratic Oath, you promised to take care of patients, and you're going to provide care. e best way to do that is to act responsibly and say this is a reasonable case, and we're going to override what the guidelines say and get surgery approved. n Why orthopedic practices should embrace non- traditional healthcare coverage By Claire Wallace O rthopedic and spine surgeons alike are finding that patients are growing increasingly frustrated with traditional insurance models. From decreasing reimbursement rates to increasing costs and prior authorization denials, practices are finding creative ways to boost revenue and appease patients. Editor's note: Responses were lightly edited for clarity and length. Question: What is the smartest business decision you made in 2024? Jeffrey Carlson, MD. Orthopedic Spine Surgeon at Orthopaedic & Spine Center (Newport News, Va.): 2024 has been a hard economic year for most people. We are finding more patients that are going without traditional insurance and finding ways outside of insurance to get their healthcare. Patients are getting tired of commercial insurance plans regulating their healthcare which can be detrimental to their ability to work and enjoy life. Many are finding paying for healthcare with cash is more affordable than maintaining their insurance through deductibles and copays. We have embraced the ideas of the free market and expanded our acceptance of non-traditional healthcare coverage. We have been aggressively pursuing pricing models that allow patients to receive healthcare from evaluation to surgical intervention. The response from patients and physicians has been overwhelmingly positive and we look forward to expanding in 2025. n

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