Spine surgeons face a constant back-and-forth with insurance companies to gain approval for surgical procedures, which has become more difficult over the past decade with the rising cost of surgical procedures and new coverage guidelines from payers.
Insurance companies are more willing to approve than in the recent past, but it takes persistence. "A lot of insurance companies have begun to fight less vigorously but it still seems an endless battle because surgeons have different expectations and priorities than the insurance companies," says Thomas Roush, MD, founder of Roush Spine in Lake Worth, Fla. "The insurance companies have to think about their shareholders and other non-patient-related entities while surgeons must focus on ways in which to optimize a patient’s condition while striving to exceed patient expectations."
When coverage is denied, surgeons can call the insurance companies for a peer-to-peer conversation about the case. Often, the person on the other end of the line isn't a spine specialist and is going through a checklist of requirements before granting coverage. "Just last week, for example, I had a patient present to my office with three months of back pain and left leg weakness and numbness in a dermatomal distribution," says Dr. Roush. "Naturally, I ordered an MRI scan of the lumbar spine with extensive documentation in the clinic note sent promptly to the insurance company. After inquiring with my office staff of the MRI results, my staff presented to me a denial letter from the insurance company for the MRI scan. After approximately 30 minutes on the phone with the company, I was told that I would receive a callback from one of their doctors that afternoon. I am still waiting on the call while the patient continues to suffer without any further knowledge of her condition."
"It's difficult to accomplish productive discourse as the insurance representative generally takes a preconceived adversarial position. Furthermore, my experience has been that no matter how much evidence and experience based support that I offer the representative, their reflexive response is simply 'no'," says Dr. Roush. "I now begin the conversation by asking the representative if there is any evidence, explanation, or logic that I can present to them to allow approval. If that person says 'no,' which is most often the case, then I don't have to go through my entire soliloquy before the denial."
If Dr. Roush can't convince the insurance company to cover a certain procedure, he suggests his patients to contact their insurance companies directly. Often times, they are able to achieve approval for treatment. The patient calls the number on the back of their insurance card to speak with the patient representative and to determine what the patient needs for coverage. Then Dr. Roush's office can provide the appropriate documentation.
"It's an extra step, but the insurance company's goal in my experience isn't to provide the best patient care; it's to provide the most cost-effective care within their guidelines," says Dr. Roush. "It's a maze to navigate because their intention is to make the process more difficult for the patient and provider. When services aren't provided, the insurance company saves money. But if you are persistent enough, you tend to obtain approval."
As the practice of medicine becomes more corporate, here are five key trends Dr. Roush sees in the future:
1. Surgeons will stop spending time fighting insurance companies. Most surgeons are already heading busy practices and don't have the resources to fight for coverage. "More and more surgeons are disconcerted and not putting up as much of a fight regarding procedure approvals and as a consequence it has become easier for those of us who do call the insurance companies to get through," says Dr. Roush. "In my experience, it has become easier to communicate with the insurance companies now than it was five years ago."
2. Technology is limited because insurance companies won't cover new innovations. "Many technological advances in surgery aren't considered by the insurance market because their algorithms aren't compatible with applying new technology," says Dr. Roush. "Most of the technology is denied but not understood by insurance companies. You might have to make three or four calls and talk to someone familiar with the technology before you can get it covered."
3. Insurance companies could succeed in limiting some unnecessary surgery. "There is a mismatch between patients, surgeons and insurance company indications," says Dr. Roush. "The interfering third party is a necessary evil to provide some regulation of the industry. But insurance companies and their representatives aren't adequately educated or experienced in the field of spinal surgery, so they become an impediment and patients are denied the best available technology for surgery."
4. Insurance companies are limiting out-of-network options for patients and spine surgery is costly enough that many patients aren't able to pay out-of-pocket. "Patients will often just settle for whatever treatment is approved," says Dr. Roush. "They might opt for a more invasive and morbid fusion instead of motion preservation because insurance companies don't cover it. Or patients might not be able to work through the entire approval and denial process. They'll wind up settling for a suboptimal treatment option simply because that specific option is approved. The irony is that the insurance companies will often spend considerably more money covering procedures that are less optimal for patients as these procedures tend to be associated with longer hospital stays and complications.”
5. Surgeons will join together in larger practices for leverage with insurance companies. "When you're in private practice, there are fewer people to fight the battles for you and make the calls to the insurance company. This preserves the obstruction," said Dr. Roush. "In larger practices, the appeals process can be centralized such that designated employees may regularly communicate with the insurance companies and surgeons may regain their focus on optimizing patient care by strengthening the patient-physician relationship."