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 The Craniospinal Center of Los Angeles discusses the way physicians should approach payer conversations and what he wants to see from physician peer reviewers.
Note: This 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. That 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. They don't have to give us their last name, but just their NPI. They 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. The 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.