Issue link: https://beckershealthcare.uberflip.com/i/170082
Sign up for Becker's Orthopedic, Spine Business & Pain Management E-Weeklies at www.BeckersOrthopedicandSpine.com or call (800) 417-2035 4. RAC audits are recouping reimbursement on some cases. Medicare officials are now reevaluating old cases and retrospectively recouping reimbursement for surgery without the proper documentation of conservative care. Even though these procedures were performed and reimbursed in the past, CMS is looking for the documentation based on current standards. "This is a really scary area because RAC auditors have gone through one or two years of cases and asked for recoupment on spine surgeries where documentation doesn't support their definition of medical necessity," says Ms. Koelbl. "You can try to combat them with physician queries. Make sure your teams have a comprehensive list of non-leading physician queries and use those during charge capture and billing as well as during retroactive denials or recoupment." RAC auditors may or may not accept these queries, but at least you have the documentation available. This comes in handy because sometimes the patient documentation on conservative care wasn't sent to the surgeons in the first place. "The worst part of the whole thing is they are sending the patient a note that their surgery wasn't medically necessary," says Ms. McKinley. "This is scary for the patient. I find the increased oversight frightening." 5. Secondary procedures get a zero. Commercial insurance companies often contract to reimburse spine surgeries with primary codes paid at 100 percent and secondary and tertiary procedures at 50 percent of the fee schedule rates. However, with new edits, some insurance companies bundle services and take a zero on the secondary procedure. This can be devastating for spine surgeons and practices. "They set billing edits to bundle secondary procedures, so these managed care and commercial payors are using edits that contradict their contracts," says Ms. Koelbl. "Those secondary procedures are getting a zero because of the edits. It's something that's happening a lot. Providers have been told to appeal these cases and provide the contract language, but you have to develop a relationship with payors to really solve the problem." Leverage this relationship with payors to get the edits removed because if you don't, you stand to lose a sizable amount of revenue. "Insurance companies sometimes change their edits and it doesn't come up with the providers until they get a denial," says Ms. McKinley. "They reduce procedure codes with mass payment. They are reducing procedure codes that are exempt from the reductions. Having the specific contract language in the contract is so important. Spine surgery can be scheduled so far in advance that something could go out of coverage and providers aren't even aware." 43 The insurance companies have a different authorization number for the hospital and the physician, and both must be on the claim. For outpatient surgery, the ASC's business office must be especially diligent about including this code. "When the business office calls the insurance company for an outpatient spine surgery authorization code, the insurance company might say outpatient procedures don't need authorization, but spine surgery always needs an authorization," says Ms. McKinley. 7. Lower reimbursement rates. Insurance companies are offering lower rates than in the past for spinal procedures, which means surgeons must come to payor negotiations armed with more than just clinical documentation; they must also bring redacted payor data to show a rate increase is reasonable in their market. "Present redacted payor data from other payors to compare their rates with other payors for high-volume procedures," says Ms. Koelbl. "If you are having coverage problems with a major player, show outcomes data along with other payor rates to help bring them on board." Figure out where you can use positive reimbursement trends to correct negative ones. Physicians have assumed the responsibility for proving their case, and payors respond best to data. 8. ACOs and bundled payments. New payment models are appearing in several marketplaces, and spine surgeons must be prepared to take more risk in their clinical decision making. "Physicians need to keep cost and revenue information so they can negotiate the appropriate rates," says Ms. Koelbl. "They don't want to negotiate rates that are too low. Accountable care organizations and bundled payments are coming, and surgeons need to make sure they are administratively sound." n register today! 11th Annual Orthopedic, Spine and Pain Management-Drive ASC Conference June 13-15, 2013 in Chicago Stay updated on payor contracts and coverage guidelines; otherwise you may find a previously covered service no longer covered when the denial comes. The Best Business Conference for Spine and ASCs Featuring 50+ Physicians Speaking, 90+ Sessions "It's imperative that physicians and practices understand what their existing contracts say, their clauses and nuances," says Ms. Rogers. "They need to be on top of this and manage their contracts to understand what the implications are for their reimbursement. Look at each contract carefully and monitor every time a check or EOB comes in to make sure they match the negotiations." Featuring keynote speakers Mike Krzyzewski (Coach K), Geoff Colvin, Brad Gilbert, Forrest Sawyer and more than 135 speakers. 6. Missing authorization code. One of the most common errors on spine claims is the lack of appropriate authorization code. The claims must include the physician and hospital authorization code. "If the payors don't see that code on the bill, they will deny it," says Ms. Koelbl. "In one situation, we found over 100 authorized surgeries that didn't have a code on the UBO4 form, and the payor denied it for no authorization even though they had it. Providers have to keep the quality assurance measures in line because they cannot lose $500,000 on an administrative error." For more information visit www.beckersspine.com.