Here are eight important concepts for spine surgeons to understand about reimbursement and collections going forward.
Sign up for our FREE E-Weekly for more coverage like this sent to your inbox!
1. Denial of bone graft substitute use. Insurance companies have been increasingly denying coverage for bone graft substitutes, especially Medtronic's bone morphogenic protein product Infuse. They would cover the product in the past for a variety of uses, including off-label, but now surgeons and hospitals are having a difficult time gaining approval and reimbursement for it.
"Infuse is approved by the FDA but it isn't approved for all types of uses," says Valerie Rinkle, vice president of revenue integrity informatics with Health Revenue Assurance Associates. "The surgeon's office might call and get approval for the spinal fusion using Infuse, but then when the hospital bills for it insurance companies won't cover it because of the approach. This is especially true for posterior and transforaminal fusion at multiple levels."
If the hospital bills for the procedure and implant and doesn't receive coverage, they are stuck with a very expensive claim. Some hospitals may ask surgeons to severely restrict or discontinue their use of Infuse and other expensive products risking coverage denials. However, surgery centers may still be open to using the product since they bill differently.
Future use of ICD-10 may help this problem because billers and coders will be able to use increased specificity for the procedure. Insurance companies will be able to identify off-label use more quickly and tighten restrictive coverage policies.
2. Insurance companies change policy without warning; watch for payer coverage updates closely. Surgeons and spine practices have begun to receive coverage denials for procedures and practices that were previously covered by insurance companies. One big example has been biomaterials, such as the new bio grafting materials which are now classified as non-covered services, even though they have been recognized and covered in the past.
"It's not the entire procedure, it's just the biomaterials that were being denied in most cases," says Barbara Cataletto, founder and CEO of Business Dynamics. "They were covered in applications for several years, but now they are considered experimental, therefore, not covered. This doesn't make sense because bone marrow aspirates had minimal physician reimbursements — $100 or so — now if you include it in your surgical case, insurance companies won't approve reimbursement for the entire case. This is unusual and I haven't seen anything like this in the past."
Keep a close eye on the insurance company website for policy updates and make sure your office staff notifies you of any changes in claim denials.
3. Payers now want spine surgeons to document the patient's full treatment before approving surgery. Spine surgeons across the country are hearing they need more documentation from each case before payors will approve surgery. Sometimes surgeons can predict the type of documentation they will need, such as proof the patient took the appropriate pathway of physical therapy and epidural injections before deciding upon surgery; other times, the missing documentation isn't quite as clear.
"Sometimes when you are asking for approval on the big ticket items, payors aren't very straight forward about what you need in your documentation," says Christopher Kauffman, MD, a spine surgeon in Nashville, Tenn., and chair of the North American Spine Society's Professional Economic and Regulatory Committee. "You can tell them how long the patient has been having problems and show them they've been through the treatment pathway, but the payor will still deny surgery because you don't meet all the requirements, but they won't tell you what the requirements are. I can't do a good service for my patients if I can't answer these questions."
Gathering all the documentation necessary can be challenging for spine surgeons, especially when patients have their non-operative care elsewhere.
4. 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 Danielle Koelbl, president of MedRev Solutions, a healthcare revenue cycle and receivable management company. "That's a lot of money when you are working on the spine. I have been suggesting that physicians and hospitals flag high-deductible 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.
5. "Peer-to-peer" reviews aren't with a "peer." When insurance companies deny coverage for spine surgery, surgeons can appeal that decision to a "peer-to-peer" review. In many cases, the insurance company's "peer" isn't a spine-focused surgeon and often is no longer a practicing physician.
"Your first appeal will be peer-to-peer, which might mean you are speaking to a retired pediatrician," says Jeffrey Goldstein, MD, Director of Spine Service, NYU Langone Medical Center's Hospital for Joint Diseases. "That isn't a peer. Your peer is a surgeon who is practicing in your subspecialty. Even doing a peer-to-peer with a sports medicine surgeon would be a stretch for a spine case."
Ask the insurance company's reviewing surgeon for their qualifications to see whether they are a practicing spine surgeon. "Spine surgeons have to wait until the insurance company's 'expert' is available and it might be a radiologist," says Dr. Kauffman. "That's not an appropriate person to go over spine cases. It can be very frustrating."
6. RAC audits could retrospectively deny coverage. RAC audits are becoming more common and could make an impact on spine surgeons' practices in the future. Even if surgeons are able to gain approval for surgery, perform the surgery and receive reimbursement, if a RAC auditor retrospectively finds you didn't have the right documentation for surgery they'll request a refund.
"The Medicare RAC auditors will give you the appropriate or updated guidelines, but that is for the future," says Dr. Kauffman. "They will want their money back for the past cases. Surgeons are not going to know what to do in this situation. They have to have the right documentation both in their office notes and in the hospital record; EMR can give people an advantage in this realm because if your practice takes the time to have different templates for herniated discs, spinal stenosis, ect., you can add to that template continuously and make sure the person has taken the right pathway for fusion. That gets the surgery approved and helps you on the back end."
EMR can help surgeons document for Medicare and private payor cases. If you don't have EMR, staff members can help you make sure patients have been through every step of the treatment pathway before requesting surgery.
7. 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."
8. Re-submit or appeal denied claims. Don't leave money on the table by tossing denied insurance claims. If the claim was denied for a coding error, fix the mistake and resubmit; if it was denied for another reason, appeal the payor's decision as far as possible.
"Insurance companies are making up bogus algorithms to deny surgery, and I don't know where they are coming from," says Hooman Melamed, MD, an orthopedic spine surgeon with DISC Sports & Spine Center in Marina Del Rey, Calif. "They aren't paying attention to the clinical notes and they are saying surgery isn't indicated, when clearly the findings are there. They are doing it hoping the patient and surgeon will give up and the surgery won't be performed. I've had denials for fusion in scoliosis and other deformity procedures where patients failed conservative therapy and they are still telling me the patient isn't a surgical candidate."
It's important to fight for coverage from the preauthorization stage, but just receiving the go-ahead for surgery doesn't mean your work is over.
"Keep in mind, pre-certification approval is in no way a guarantee of payment once the services have been rendered and a claim has been submitted for reimbursement," says Mr. Weiss. "That is why it becomes critical for them to have staff that is highly educated and trained in the 'business of medicine' so they can have the requisite skills necessary to secure the reimbursements the presence has emitted you to."