Amid policy shifts like the No Surprises Act, insurers are deploying increasingly sophisticated strategies to delay, deny or reduce payments for anesthesia services, four anesthesia leaders told Becker’s.
Editor’s note: Responses have been lightly edited for clarity and length.
Question: What strategies are you seeing insurers use to delay, deny or reduce payments?
Andy Briggs, CRNA. (Colorado Springs, Colo.): It seems that insurance companies today look at billing with a very broad scope. While this can be an advantage, the greatest downside is when costs are “shuffled” from one place to another. Technology and new equipment have advanced surgical procedures in many ways (robotic surgery, intraoperative CT scans, neuromonitoring for spine procedures, just to name a few). There seems to be a relationship between the rising cost of procedures and the measurable decline in anesthesia reimbursements, where it appears that money is shunted away from other areas to balance the rising cost of another. The reality now is that anesthesia stands to suffer the most from these incremental losses. The cost of running a functional anesthesia group from 2001 to 2025 has risen 39% whereas Medicare has only increased anesthesia reimbursement by 11% over this time frame. The lifeblood of our specialty, (aside from vigilant patient safety), is our ability to understand a multitude of conditions and interventions across a vast playing field. The future of our profession will depend on our willingness to evolve that skill set further into the business world and educate the several “moving parts” of healthcare about the long-term implications of short-sighted strategy.
Katy Dean, CRNA. Chief Nurse Anesthetist at TKMAnesthesia (Newport News, Va.):
1. Insurers are getting more aggressive, and more creative, in avoiding payment. We’re seeing more denials for time discrepancies, claims being reprocessed months later with money pulled back, and even outright rejections for technicalities like modifier confusion (the codes that show who provided care).
2. They’ll also bundle services that should be billed separately. For example, if I do a regional nerve block for pain control after surgery, insurers often say that’s included in the anesthesia charge, when it’s not. That block requires separate expertise, time, and documentation.
3. Prior authorization is becoming a major barrier too. Even for routine procedures or pain management, insurers are demanding approvals in advance, and if you don’t jump through their hoops, they’ll deny the claim after the fact, regardless of medical necessity.
4. Some insurers even lease out-rate agreements without telling us. They call it “silent PPOs.” They use our hospital’s in-network status to reduce what they pay us, without us ever signing that agreement.
5. At the end of the day, these tactics don’t just affect providers, they delay care, frustrate patients, and contribute to burnout in a specialty already stretched thin.
Antonio Hernandez Conte, MD. Former President of the California Society of Anesthesiologists: Insurers and third-party payors are resorting to a variety of tactics to gradually reduce payment for anesthesia services. As was recently witnessed, UnitedHealth attempted to eliminate time-based anesthesia reimbursement and replace it with a fixed anesthesia fee based upon the surgical procedure; this tactic was met with large public outrage, and UnitedHealth discontinued the maneuver. However, the New York state legislature introduced a bill to actually allow this practice to occur. Several states have introduced bills to counter predatory insurance tactics that reduce payment for anesthesia services. Additionally, Blue Cross and UnitedHealth are no longer covering payments for ASA 3 and ASA 4 physical status modifiers. Again, these predatory initiatives further threaten the solvency of anesthesia practices and force groups to further rely on hospital subsidies to ensure fiscal solvency. The No Surprises Act remains a continual burden for anesthesia practices as insurers delay payments for up to 90 or 120 days even if anesthesia groups are successful in the arbitration dispute resolution process.
Kelly Petz, DNAP, CRNA. KellCo Anesthesia (Port St. Lucie, Fla.): Some of their actions have included the following:
1. Paying CRNAs at 85% of the fee schedule based on their license as an advanced practice nurse.
2. Only recognizing 100% reimbursement when a CRNA is supervised by a physician anesthesiologist.
3. Denying reimbursement for procedures CRNAs are authorized to perform under state licensure laws.
4. Refusing to reimburse autonomously practicing CRNAs billing under the QZ modifier.
5. Refusing to contract with CRNAs at all.
This discrimination significantly impacts rural facilities that run on tight margins and rely on the CRNAs who are more likely to work in these communities.
