Surgeons have been seeing sudden and unannounced coverage changes for common spinal procedures over the past year, leading to denied claims and a loss of revenue and resources. The strategies used by many insurance companies to rein in costs have had a significant impact on spine practices and patient care. "The industry has realized that the cost of spine surgery is too high to continue down the old path," says Barbara Cataletto, MBA, CPC, CEO of Business Dynamics. "The industry is manipulating CPT and coding regulations and reducing reimbursement in several different ways."
Here, Ms. Cataletto discusses how these coding and reimbursement changes are impacting spine surgeons and practices around the country, and what spine surgeons can do to fight back.
1. CPT has bundled several codes that were separately billable. These new CPT regulations are now bundling codes with high level of service reimbursement under one code such as the interbody and lateral fusion codes as well as the removal of old instrumentation and insertion of new instrumentation in revision surgeries. CPT has bundled the reimbursement for these procedures and the bundling is not realized until the practice receives the payments.
"Many of these changes were unannounced, such as the bundled instrumentation with revision surgeries, which has really hit surgeons hard considering it takes time for the removal of instrumentation in the revision procedure; the surgeon won't be paid separate if it is performed with the insertion of the new construct," says Ms. Cataletto. "That is frustrating and unfair for surgeons doing this type of work, and most practices weren't aware of this important change until they received a denial."
Surgeons are also seeing insurance companies bundle codes that were previously billed separately, such as the use of bone marrow aspirates with other procedures. Insurance companies have begun denying entire claims where bone marrow aspirates were billed separately; this action has been devastating for spine practices, many of whom were unaware of the change.
"I would like to see the industry have more disclosure," says Ms. Cataletto. "I don't see the current trend improving until there is true transparency and the industry at large has a chance to counter specific changes to CPT or reimbursement prior to its enactment. There are no increases in RVUs for these new coverage updates, so surgeons are doing more work and taking on more risk for less reimbursement."
2. Denial for previously covered treatment. 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 Ms. Cataletto. "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."
While insurance companies may have a history of denying single part coverage for an entire procedure that was previously covered, denying an entire case when a non-covered procedure is involved is unprecedented. This trend has been especially disconcerting for surgeons and patients since insurance companies are denying treatment and procedures that are cleared by the FDA.
"This is a newer problem over the past few months," says Ms. Cataletto. "The transparency in the decision making isn't there so no one knows where this is coming from. Surgeons can't respond and patients don't know this is happening, and they play no part in the process of any debate with regard to insurance coverage. Patients who want the best treatments that are FDA approved aren't allowed to participate because carriers don't believe the patient's input is warranted."
Local and national medical societies are taking on some of the coverage challenges and denials spine surgeons are seeing on a more universal level. Surgeons who are interested in making an impact on coverage decisions and policies in the future can become involved with these societies and their advocacy efforts.
"The local societies have an obligation to listen to what is happening in their area, but only if the surgeons openly discuss the common issues" says Ms. Cataletto. "Attend a local meeting and make the issues personal, so it will stir up the local community of physicians. Many of the national societies have open lines with the industry, surgeons, implant companies and patient advocates for the appropriate approvals process."
3. Preauthorization is a more rigorous process than in the past. The preauthorization process has become much more rigorous over the past few years, taking surgeons away from their patients to debate clinical guidelines and treatment decisions. This has become especially prominent in spinal fusion cases, where sometimes even providing the essential information about failed conservative treatment leads to a peer-to-peer review.
"In the past, surgeons could have their office staff discuss coverage issues with the insurance companies; now they are asking questions only the surgeons are able to answer and extending the reviews beyond staff," says Ms. Cataletto. "The surgeon has little choice but to comply and by doing so, it encumbers their ability to work with patients."
The additional time on the phone with insurance company costs surgeons both in their patient relationships — less time spent with patients in order to take these phone calls—as well as financially, since they aren't reimbursed for time spent on the phone.
"You have to go through three or four levels of appeals and sometimes even then only part of the case is approved or a full denial is rendered," says Ms. Cataletto. "If the coverage isn't approved, patients may be forced to pay for the surgery themselves or figure out the next available treatment option. The patients and physicians are left in a dilemma of a situation as to the next steps should the carrier disagree with the treatment. Even if the patient has coverage, it doesn't mean the carrier will cover the surgical care and this has a significant impact on everyone."
When advocating for additional coverage, surgeons must frame their position so it focuses on providing the care patients deserve and not merely on reimbursement levels.
"We have to change our focus from the reimbursement position to a patient care and coverage position for society at large to take us seriously about our motivations," says Ms. Cataletto. "If we put patients first, everything else will follow. If patients are involved with advocating for their coverage, there is a team approach to tackling these issues. Both patient and surgeon involvement in responding to denials is critical. At the end of the day, it's all about the patient."
Providers can go to the state insurance board to discuss the impact these changes are having on their practice. "Extend complaints to the state insurance boards," says Ms. Cataletto. "That's another key avenue that they can explore in order to have their voices heard as to how these decisions are impacting patient care."
4. Appeals processes are taken to the highest level more often. Surgeons seeking to appeal an initial denial of coverage decision are jumping through more hoops than ever before. They have become steadfast in their efforts to tackle several levels of appeals, and some practices have hired additional staff members just to manage appeals with insurance companies.
"The appeals process is much more difficult than it was in the past," says Ms. Cataletto. "To win, you need to go to the highest level of the appeals process and that's extremely costly. Most practices don't have what they need in manpower to even reach that level. Even if they have a large collections staff, they might not have staff members who are qualified at the highest levels."
Regulations on fighting denials have also changed to make the appeals process tighter. This is forcing some spine surgeons to sell their small or independent practices to a hospital, while others choose to merge or join larger physician groups.
"It seems like the whole spine industry is in a whirlwind as to who is going to win: Is it the surgeon or the insurance company, and in the middle is the patient," says Ms. Cataletto. "We really have a lot of cards stacked against us and at the end, in order to get reimbursed, the practice must ultimately be responsible to fight and pursue these appeals within a very specific timeframe or they lose the appeals option."
However, it is important that extra time and effort be taken now to prevent insurance companies from continuing this practice to include an even wider range of procedures and claims in the future. "The position taken by surgeons in the past had been that someone else would take care of it; this notion is no longer a tangible option” says Ms. Cataletto. "They have to be involved in the appeals process and provide a presence in their local societies; otherwise, any costly coverage is in danger of going down the same path in the future."
5. Post-surgical denials could mean Medicare doesn't cover medically indicated procedures. In the new policy recently released by Medicare, auditors are finding incomplete documentation indicating spine surgery can be denied reimbursement post-surgically, even if the procedure was medically indicated. Surgeons and providers must have all the documentation of failed non-operative treatment on file.
"If your documentation from the hospital does not include the physician notes of conservative care through surgery, you will not be paid for the hospital stay or physician work," says Ms. Cataletto. "They are doing a post-surgical audit and denying coverage. Post-surgical denials for coverage are based on whatever conservative treatment patients had in the past."
Post surgical denials of services weren't common in the past, but now surgeons are seeing them more often. "They are doing the audits now and they have six levels of appeals before deciding to pay," says Ms. Cataletto. "Most of the post-surgical denials are reversed if the documentation is made available. There is more medical necessity denials now than in the past and it takes time to deal with them."
It is in the best interest of both doctor and patient to have all required documentation well supported and complete at the time of filing for each and every case.
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