Here are four reimbursement issues currently impacting spine and orthopedic surgeons:
Declining CMS pay
CMS cut overall physician pay by 1.25% for 2024. Additionally, some physicians could face more cuts due to the cost-performance category of the merit-based incentive payment system, which could reduce Medicare payments by up to 9%.
These cuts are likely to persist. CMS' 2025 proposed physician fee schedule includes a 2.8% pay cut.
Between 2001 and 2021, reimbursements for spine procedures decreased by 33.8% when adjusted for inflation.
"The biggest threats to the orthopedic industry are rising costs and decreasing reimbursement," Matthew Harb, MD, an orthopedic surgeon at the Centers for Advanced Orthopaedics in Bethesda, Md., told Becker's. "The costs associated with running an orthopedic practice have significantly increased, a trend that has become incredibly evident in the past few years. The cost of rent, payroll, supplies, equipment and employees have all surged in recent years. This forces practices and providers to either see more patients in shorter amounts of time, cut staff, shut down practice locations, or fall victim to a private equity buyout — all of which has diminishing effects on patient care. To make the situation worse, reimbursement has failed to keep up with inflation. Instead, it has declined year over year, stressing the situation further."
Value-based care models
Value-based care has been adopted by some spine groups as an alternative to fee-for-service payments, but some leaders say it has not met expectations and may present new challenges in securing reimbursements.
"When value-based care was initially introduced in the form of ACOs and bundled payments, payers thought that this would be a reasonable method for controlling costs without sacrificing quality," Alok Sharan, MD, a surgeon and the president of Edison, N.J.-based Spine and Performance Institute, told Becker's. "It is clear now that value-based care has not been able to deliver on those promises."
Spine and orthopedic surgeons are also facing issues in understanding what value-based care means to each payer.
"To a payer it means one thing. To a patient maybe it means another, and to a provider maybe it means another thing," Michael Havig, MD, an orthopedic surgeon with Naples, Fla.-based OrthoCollier, said. "It's probably a Venn diagram where they all intersect in the middle. But the question is, what is that intersection like? What are the key components of it for a provider, for a patient and for a payer? That's not easy to determine."
Prior authorizations
Prior authorizations and other administrative hurdles are creating barriers for spine and orthopedic surgeons in providing patient care and securing reimbursements.
"Without a doubt the most dangerous trend in spine-adjacent fields is the minefield of prior authorization (which consumes endless time and phone calls with no guarantee of payment) and the dubious medical literature the insurance companies cite to justify harming their customers," Eric Mehlberg, MD, a pain management specialist at SurgiComp in the Denver area, told Becker's.
Around 97% of providers have had delays or denials for necessary patient care due to prior authorization requirements, according to the Medical Group Management Association's 2023 "Regulatory Burden Report."
Another emerging challenge is the rise of prepayment reviews.
"The next big payer challenge, and I have already seen this, is prepayment review," Brian Gantwerker, MD, a spine surgeon at The Craniospinal Center of Los Angeles, told Becker's. "That is when you get the surgery authorized, you do the surgery, then before they pay you, they revisit the claim. It is yet another step that allows the insurer to place more delays on your payment. Until we streamline this process, tighten it up, the skullduggery will continue."
Despite efforts to minimize the burden, many spine and orthopedic surgeons are seeing complications related to prior authorization rise.
"The prior authorization process has become more and more arduous," Vijay Yanamadala, MD, a spine surgeon at Hartford (Conn.) HealthCare, told Becker's "We can clearly see a difference in the pre-COVID versus post-COVID era in terms of the number of denials we are getting for similar procedures. Unfortunately, the prior authorization process is not achieving its purpose — preventing unnecessary interventions. Instead, it is simply creating more and more difficult barriers even for patients who urgently need surgery. We need to work together to ultimately come up with a better process that truly gets every patient the right care that they need."
Claims denials
Spine and orthopedic leaders are also facing a rise in claims denials, even for procedures that were previously approved.
"We are starting to see rescinds from six months to a year ago where we were paid and now they're rescinding those payments," Shannon Cameron, COO of the billing operations for Harvard Medical Faculty Physicians in Boston, told Becker's. "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."
In 2024, 77% of respondents noted that payer policy changes are happening more frequently, up from 67% in 2022, according to Experian Health's "2024 State of Claims" survey. Additionally, 67% of respondents said reimbursement times are increasing in 2024, compared to 51% in 2022.
Insurance companies are even trying to recoup payment on procedures that received prior authorization.
"Just because you have a prior auth, it's a huge myth that it's going to get paid," Ms. Cameron said. "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."