8 Ways to Combat Spine Surgery Claim Denials
1. Look out for bundled codes. Insurance companies have recently bundled several codes together to reduce reimbursement for the overall episode of care. Unbundling these codes to increase reimbursement is unlawful, so pay attention to these changes.
"As with all surgical specialties over the years spine procedures have seen many services that were once paid separately bundled as a way of saving payors money," says Sean Weiss, vice president and chief compliance officer for DoctorsManagement. "The coverage guidelines with every revision seem to have more and more exclusions or restrictions to them. Again, insurance coding and billing is a game the payors have forced physicians and their staff to learn how to play and just when you believe you have it figured out they have changed the rules on you again."
There is little spine surgeons can do to combat bundling codes. However, lobbying congressional representatives can make an impact as Congress seeks to reform the healthcare system in the future.
"Things continue to change and unfortunately until physicians get a stronger voice on Capitol Hill they will not be changing for the better," says Mr. Weiss. "It has gotten harder and harder to not only get paid for spinal procedures but to actually be paid what a surgeon is entitled to."
2. Work with coding professionals. Coding for spinal procedures is complex, and only focused expertise can optimize returns. Consider outsourcing billing responsibilities to experts in the field if you don't have the resources to hire an expert in-house.
"Spine surgeries are one of, if not the most, challenging and complex of all surgeries to code," says Mr. Weiss. "This is why so many of our orthopedic clients outsource this portion of their coding to us because of the challenges coding these procedures presents."
If you do not have the staff thoroughly trained, then consider seeking help from a consultancy with qualified staff to ensure a focus on spinal procedures.
3. Argue for medical necessity. Payors are increasingly denying spinal procedures based on "medical necessity," or lack thereof. Insurance companies claim surgery isn't medically necessary for a variety of reasons, including in situations where approval was readily granted in the past.
"There have been class action settlements in recent years — approved at various times between 2003 and 2006 — that have penalized insurers for unethical and unfair business practices," says Mr. Weiss. "The Second Circuit Court of Appeals decided numerous cases where medical necessity is mentioned. However, only one case actually described what the term means in absence of a definition in an insurance plan's documentation, saying 'unless the contrary is specified, the term medical necessity must refer to what is medically necessary for a particular patient, and hence entails an individual assessment rather than general determination of what works in the ordinary case."
Insurance companies such as Aetna, Cigna and Humana have entered into settlement agreements with more than 900,000 physicians and state and county medical societies in a class action lawsuit. However, settlements have expiration dates and vary by payor, so at some point the payors will not be bound by the definition of medical necessity within the settlements.
"I encourage physicians to play an active role in writing the appeal letters for claims that have been denied due to medical necessity, as you do not want to leave that to the discretion of a non-clinician," says Mr. Weiss. "However, for the practices that still cannot get the physician to write the appeal letter of medical necessity, there is simple language practice staff can use."
4. Re-submit or appeal denied claims. Don't leave money on the table by tossing denied insurance claims. If the claim was denied for a coding error, fix the mistake and resubmit; if it was denied for another reason, appeal the payor's decision as far as possible.
"Insurance companies are making up bogus algorithms to deny surgery, and I don't know where they are coming from," says Hooman Melamed, MD, an orthopedic spine surgeon with DISC Sports & Spine Center in Marina Del Rey, Calif. "They aren't paying attention to the clinical notes and they are saying surgery isn't indicated, when clearly the findings are there. They are doing it hoping the patient and surgeon will give up and the surgery won't be performed. I've had denials for fusion in scoliosis and other deformity procedures where patients failed conservative therapy and they are still telling me the patient isn't a surgical candidate."
It's important to fight for coverage from the preauthorization stage, but just receiving the go-ahead for surgery doesn't mean your work is over.
"Keep in mind, pre-certification approval is in no way a guarantee of payment once the services have been rendered and a claim has been submitted for reimbursement," says Mr. Weiss. "That is why it becomes critical for them to have staff that is highly educated and trained in the 'business of medicine' so they can have the requisite skills necessary to secure the reimbursements the presence has emitted you to."
5. Speak with insurance company medical directors. Insurance companies often employ former physicians as advisors or medical directors to assist with case approvals. Many of these physicians are general surgeons or physicians without specialty training; even on the occasion that one of these physicians has a background in orthopedics, it takes someone with subspecialty knowledge in spine to really understand the case.
"You really need a true qualified spine surgeon who is currently in practice to review cases thoroughly and really look at the notes to give coverage opinions," says Dr. Melamed. "The best way to do it is to have an independent reviewer look at these cases. I have very comprehensive notes, but I've found reviewers just skim them and say 'yes' or 'no.'"
Appealing to a practicing physician in these cases can also have an impact on coverage. If the reviewer hasn't practiced surgery in 15 years, it's unlikely he or she will be up-to-date with techniques, technology and other changes in care delivery. Reviewers currently follow strict guidelines for approving cases without considering individual needs.
"Guidelines should not be set in stone as a standard of care," says Dr. Melamed. "Not every patient fits into the exact criteria, just like not every patient has the textbook disease. There are guidelines that should be there, but they should be evaluated on a case-by-case basis."
6. Involve the patient in the appeals process. The insurance company doesn't have to answer to the surgeon for care; the company must answer to its customer, which is the patient. When insurance companies deny care for appropriately indicated patients, these patients should become involved in the decision appeals process.
"I write a letter of appeal about why the surgery should be authorized and ask the patient to call their insurance company and yell at them," says Dr. Melamed. "This is a breach of contract and the insurance company is more likely to approve care after hearing directly from the patient. The most important thing is for the patient to become proactive."
By his estimate, Dr. Melamed spends approximately an hour per week dealing with coverage denials and writing the letters of appeal. "The patient doesn't know what to do after coverage is denied and they think they don't have any other options," says Dr. Melamed. "Get the message out there that patients should become involved because insurance companies are obligated to provide appropriate services."
7. Connect patients with attorneys. When insurance companies continue to deny medical necessary treatment, work with patients to hire an attorney that can take their case. Insurance companies are contracted to provide care for patients and bringing an attorney onboard shows you are willing to fight for coverage.
"I have learned that you need to fight the insurance company and get attorneys involved," says Dr. Melamed. "Have the patient start calling the insurance company with their attorney and then all of a sudden they will start approving things. Coverage is a problem, especially with fusions."
Fusions have come under fire recently for overuse, but denying all coverage leaves a good portion of the patient population who could benefit from treatment without further options.
"They are denying cases that should be done," says Dr. Melamed. "There are some spine surgeons out there who are abusing the healthcare system and offering spine surgery to patients who aren't good candidates, so I can see why insurance companies are skeptical. However, you shouldn't punish the good guys for a few bad apples; most spine surgeons aren't unethical."
8. Advocate for increased coverage. Physicians must take a more active role in advocating for their services, both on Capitol Hill and to insurance companies. This requires becoming familiar with the business of medicine and leveraging their quality of care to maximize reimbursement potential.
"Physicians have to take an active role in the business side of medicine," says Mr. Weiss. "It is important to understand specialty societies are only as strong as their members' demand them to be. There needs to be a strong voice advocating for physicians on the Hill to ensure they are being heard as loud and clear as the insurance companies."
Physicians should enlist staff members to help them pinpoint small issues before they turn into big problems.
"Physicians need to communicate the importance of communicating with [their staff] so they are aware when things are not going as swimmingly as they believe," says Mr. Weiss. "There is nothing worse than having to tell a physician they are not getting their quarterly bonus."
More Articles on Spine Surgery:
5 Healthcare Reform Threats to Spine Surgeons & How to Overcome Them
7 Cost Cutting Strategies for Spine Surgery
Spine Patient Data Gathering of the Future: Q&A With Drs. Anthony Asher and Matthew McGirt of N2QOD
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