Insurance company coverage and reimbursement for spinal procedures has been changing rapidly over the past few years, and more changes are likely in the future. Valerie Rinkle, vice president of revenue integrity informatics with Health Revenue Assurance Associates, discusses three of today's biggest trends and how surgeons can overcome them for success in the future.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 Ms. Rinkle. "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.
"It's interesting because there is a difference in how hospitals and surgery centers bill for the procedure," says Ms. Rinkle. "HOPDs will break out a revenue code for the implant while ASCs do not. It's harder for insurance companies to determine bone graft substitute use on an ASC claim."
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.
"By raising the surgeon's awareness and asking them to change their use, the hospital becomes more explicit about the preauthorization process," says Ms. Rinkle. "Some are asking surgeons to let them know if they intend to use Infuse. Others are questioning the manufacturer sales representatives who assist in the operating room because they might not alert surgeons if they are using Infuse in an off-label way that won't be covered."
2. More conservative treatment before surgery is authorized. Insurance companies around the country are tightening surgical authorization guidelines to require a period of documented conservative treatment before undergoing spinal fusions. The Centers for Medicare and Medicaid requires six months of conservative treatment before hip replacement surgery, and Ms. Rinkle sees spinal surgery coverage following close behind.
"For issues with back pain, there are likely to be coverage determinations for physical therapy and other types of lower cost services before you can get to spinal surgery," says Ms. Rinkle. "I think they will enforce it more in the future, within the next year or two. As a result, surgeons will have to coordinate more with primary care physicians."
Primary care physicians will have to share medical records with spine specialists so they can prove the patient failed conservative treatment before recommending surgery. Otherwise, the patient will have to repeat conservative care to meet requirements from their insurance company.
"In some regions, there is a question about whether the surgeons or the primary care physicians will manage conservative treatment," says Ms. Rinkle. "Accountable care organizations will want the coordination out of the primary care physicians. They will need to document back pain more often because their notes could start the clock ticking on addressing back pain issues and capturing patients' complaints."
When patients arrive at the primary care physician's office with a cough or another ailment, but mention back pain, the physician should document that and watch the progression of pain so the patient receives the right treatment at the right time. Spine surgeons and specialists can help educate primary care physicians about how to recognize back pain in their patients and where to guide them for care.
3. Measuring patient satisfaction and quality. Across the board insurance companies are asking for more quality of care documentation and reimbursement from government payors — and some private payors — will depend on patient satisfaction levels in the future. Spine surgeons must prove their patients have positive outcomes and are satisfied with their visits.
"The government is trying to measure spine surgeons for patient satisfaction, and there is some difficulty in how they will do that," says Ms. Rinkle. "There is conflict between the pain patient wanting to get resolutions quickly when they see the specialist, but insurance companies' coverage policies might send them back to conservative treatment."
There are some factors of the patient's experience surgeons can't control, especially when the patient has experienced pain for a long period of time. However, if surgeons can maximize their outcomes and minimize complications and failed surgeries, their patients will report a more positive overall experience. Throughout the process, spine surgeons should maintain a good relationship with referring physicians so they can set expectations for their patients.
"Spine surgeons should be looking to reach out to primary care for a clear pathway for conservative treatment," says Ms. Rinkle. "Then, they should clearly define the pathway and stay in contact with the primary care referral base. When patients know what to expect, they report higher patient satisfaction."
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