Spine and orthopedic groups are strengthening their revenue cycle teams and clinical documentation improvement programs to stay ahead of insurance coverage policy changes, several leaders said during the Becker's 21st Annual Spine, Orthopaedic & Pain Management-Driven ASC Conference in June.
The most prominent tactics to avoid or prolong payment is enforcing prior authorizations and coverage denials. Shannon Cameron, COO of the billing operations for Harvard Medical Faculty Physicians, said her organization's clinical documentation improvement program has paid for itself 10-fold to meet prior authorization requirements and avoid billing errors.
Prior authorizations and denial practices are under scrutiny by the federal government, and now insurance companies have pivoted strategies.
"We are starting to see rescinds from six months to a year ago where we were paid and now their rescinding those payments," said Ms. Cameron. "They are sending review letters requesting medical records, which not only puts a huge administrative burden on us, but it blows up the AR aging. Most importantly, the emphasis is on the documentation. You have to have a strong force of clinical documentation improvement staff to make sure that education is out there by payer policy."
Insurance companies are even trying to recoup payment on procedures that achieved prior authorization.
"Just because you have a prior auth, it's a huge myth that it's going to get paid," said Ms. Cameron. "Diagnosis in and of itself is not enough to support that claim. That's why they're going back and asking for those medical records, which is nothing new. They've been doing that for years, but this recent tactic is huge. If you don't have the documentation in place to start, then those are going to turn into denials and you're going from payments to flipping back a year later to a denial."
Adam Bruggeman, MD, a spine surgeon at San Antonio-based Texas Spine Center and chief medical officer of MPOWERHealth said he's seeing post-authorization clawbacks intensify as well.
"Essentially you'd perform the procedure and then after the procedure, using all the same data they asked for going into surgery, they're now asking hospitals, surgery centers and doctors again to confirm that they really should have approved the surgery the first time and then they're clawing back the money, or not paying the money as a result," he said.
Dr. Bruggeman's team is trying to stay proactive and educate physicians so all the information is in place when payers make the requests.
Columbia (Mo.) Orthopaedic Group spends hundreds of thousands of dollars to employ a robust team to deal with insurer requests. They've educated surgeons about the approved codes and processes for notifying the billing team if extra work is done intraoperatively.
Andrew Lovewell, CEO of Columbia Orthopaedic Group, said one big payer asked for information about 6,000 total joints performed at the group's surgery center to potentially claw back payments.
"They're going back and retro trying to deny implants we put in from six months ago. They're doing a huge sweep," said Mr. Lovewell. "They've hired a third party and then we're spending money and time sending all these records back to them and they approve every single one of them. It's just a nuisance headache."