Becker's Spine Review

42 Sign up for Becker's Orthopedic, Spine Business & Pain Management E-Weeklies at www.BeckersOrthopedicandSpine.com or call (800) 417-2035 8 Factors Impacting Spine Surgery Coverage Rates By Laura Miller H ere are eight significant factors making an impact on spine surgery coverage rates. 1. Documentation of conservative care. Payors are demanding more documentation of conservative care today than in the past, and depending on spine surgeons to produce that documentation. Each insurance company has defined coverage policies for spinal surgery and many will deny care unless protocol is followed. "We are seeing payors increasingly push for stronger documentation of conservative treatment plans prior to non-emergent surgery," says Danielle Koelbl, president of MedRev Solutions, a healthcare revenue cycle and receivable management company. "I suggest spine practices make sure their teams are reviewing top volume payor qualities to ensure they are following conservative care pathways. We don't want the payors dictating care, but it's important to know what conservative care treatment plans they require, what they deem standard of care and figure out whether that's in line with what your physicians perform and suggest." Even after following protocol, insurance companies may still deny care. However, insurance companies may respond positively to data collection. Tracking outcomes and providing this information to top volume payors can help providers take control of their payment plans in the future. 2. Patients are paying more with high deductible plans. High deductible insurance policies are becoming more popular and people are unwittingly saddled with huge medical bills after surgery. Payors may approve surgery for these high deductible plans, but a huge portion of the bill falls on patients' shoulders and providers must have a plan to collect from them. "When the payment comes in, patients might be on the hook for 30 to 50 percent of the payment," says Ms. Koelbl. "That's a lot of money when you are working on the spine. I have been suggesting that physicians and hospitals flag highdeductible and co-insurance plans that have caps up to $20,000 because they can be hurtful to the bottom line when you are working with spine. Have your access teams verify more than just eligibility; look at effective dates and deductible amounts, and discuss them with the patients." Gathering this information beforehand will lead to better patient collections upfront and give physicians a better understanding of cost versus reimbursement before surgery. "It's sad that the risk is being shifted to the patient and they have no idea that they have an enormous bill," says Kendra McKinley, president of Doctor's Billing, a medical billing and consulting company. Danielle Koelbl 3. "Medical necessity" is being questioned. Spine surgeons are finding more denials based on medical necessity than in the past; insurance companies claim a procedure isn't a medical necessity because the patient doesn't fit into their criteria for coverage. "Getting insurance companies to understand medical necessity as an individual assessment is a challenge," says Ms. McKinley. "Spine surgeons need case studies and outcomes data to explain why the surgery is still critical." Figure out what the guidelines are for insurance companies and develop a relationship with the medical director, as well as other executives, at those companies to broaden coverage in unique cases. Kendra McKinley "What we are seeing now more and more is payors starting to reevaluate their policies on what they will and will not cover in spine," says Marcy Rogers, president and CEO of SpineMark, a developer of spine centers of excellence and spine research organizations. "Five to 10 years ago, there wasn't a single payor that had coverage rules about spinal fusions. Now, they all have strict guidelines." Each payor has its own guidelines and spine surgeons must be familiar with the guidelines for each patient they cover; otherwise, surgery may be denied and they will have to go through the appeals process. "It's really important to get the patients involved in the appeals process because at the end of the day, insurance companies respond more rapidly to patients being upset about their care than the physicians," says Ms. McKinley. "Be available to do the peer-to-peer reviews and don't take 'no' for an answer." Form a relationship with insurance companies in your marketplace to position yourself for partnerships in the future. "Facilities and physicians have to maintain a regular scheduled payor education program and meet with payors voluntarily on a monthly basis to educate them on credentialing," says Ms. Rogers. "Show payors what is new about your practice and what separates you from other organizations. The key going forward will be to overcome the hammer spine surgery is facing with the perception of over-utilization." Marcy Rogers

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