Marc Cohen, MD, a spine surgeon based in New Jersey, discusses four big coverage challenges for spine surgeons and how changes should be made to the system in the future. 1. Guidelines are unrealistic. Insurance companies have set guidelines and protocol for approving or denying surgery and often fail to take unique situations into consideration. Additionally, some guidelines may be based on outdated or poor quality studies about outcomes for the procedures.
"They have set their own guidelines and protocols with their own consultants," says Dr. Cohen. "They are questioning the surgeons who take care of the patients and understand the disease. They are making it difficult for spine surgeons and neurosurgeons to provide the surgical approach."
Insurance companies often deny surgery during the pre-certification because the patient's situation doesn't match their guidelines. In the future, spine groups or organizations may play a more active role in developing widely accepted guidelines for approving different treatments.
"We need to go to the insurers and set guidelines for payment in situations where the patient needs surgery," says Dr. Cohen. "That can only be done with data information and by spine societies being financially and politically supported by the surgeons to go to the insurance companies to state our case."
2. Too much documentation is required. Surgeons are spending more time documenting their patients' conditions and failed conservative treatment to meet insurance company requirements, which means less time providing patient care. Sometimes the documentation requests go back several months, or before the spine surgeon was involved with the patient, and the surgeon's office staff must corral that information from other providers.
"Payors are asking surgeons to provide documentation that goes back months or years with conservative care, and that can be difficult to provide," says Dr. Cohen. "Then if you are denied, you have to go through the appeals process and those layers can be very cumbersome. This means you are spending more time at your desk reading the charts, writing letters and looking for documentation to support the surgery."
Some physicians are hiring extra staff members to track down documentation and provide answers to the appeal. Even after an appeal is successful and the surgeon receives approval, the insurance company will want more information about how the surgeon will perform the case.
"The payor asks the surgeon how he will do the surgery, what technique will be used and what the device will be," says Dr. Cohen. "It puts the surgeon behind the 8-ball to decide whether he is comfortable doing a procedure with instrumentation approved by the payor instead of performing the procedure he knows is his best."
3. Peer-to-peer reviews aren't with spine specialists. If the initial stages of a denial appeal aren't successful, the spine surgeon can talk to the insurance company's medical director about the individual case. However, that medical director often isn't a spine surgeon, or even an orthopedic specialist.
"They hire people who aren't practicing medicine anymore and aren't spine specialists; these people are reading guidelines from a book," says Dr. Cohen. "It is an unfair process because you aren't talking to someone on the same level as you."
Practicing physicians who have an intimate knowledge of the spine would ideally be in the position to discuss the unique qualities of each case and evaluate whether surgery would be the most effective treatment.
"I'd rather see real surgeons who are involved in patient care and understand the patients' problems and best treatments for the patient to give more input in the system," says Dr. Cohen. "This would make the system much more functional and usable so that every day spine physicians do not have to spend a significant amount of time doing paperwork, making phone calls and appeals, particularly in an environment where reimbursements are coming down."
4. Retroactive denials of spine surgery. In some cases, even after the surgery is approved and performed, insurance companies can retroactively deny the procedure because their policies have changed.
"What happens is the CPT codes are submitted and then the insurance companies decide they don't like the code or have a question, so instead of paying for it they kick out the whole claim and deny payment," says Dr. Cohen. "All of a sudden they've done a review with some physician and decided retrospectively that the patient didn't need the surgery so they will deny payment."
In these situations, the surgeon has run out of options for payment on the retroactively denied claim; however, surgeons still have the ability to exert more control over future claims situations.
"The only thing surgeons can do is be more proactive to gain back control of the system," says Dr. Cohen. "Try to be more proactive to get a handle on the future. The only way we can do this is getting back to the fact that we must show data and outcomes proving we provide a legitimate service and that our procedures are good, safe and cost-effective."
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