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What happened when an insurer rescinded surgery approval after the case started

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Anthony Romeo, MD, executive vice president of the Musculoskeletal Institute of DuPage Medical Group in Downers Grove, Ill., was ready to perform orthopedic surgery on a sedated patient earlier this summer when his office received a surprising call.

The patient's insurance company was on the other end of the line, notifying Dr. Romeo's office that the code on the patient's prior authorization request was wrong and it would no longer pay for surgery that day.

"My office called me immediately and said, 'You have to stop,'" Dr. Romeo said during a session at the Becker's Orthopedic, Spine + ASC Virtual Event on Aug. 12. "I said, 'What do you mean? She's asleep on the table.' That is the honest truth."

Dr. Romeo called the insurance company for an explanation and was told he would need to conduct a peer-to-peer review before gaining approval for the surgery. Dr. Romeo was not deterred. He decided to wait on the line until the reviewing physician was ready so he could move forward with the procedure.

Fifteen minutes later, the reviewing physician was available.

"They did have the wrong code. We changed the code, and I immediately got an approval reference number," Dr. Romeo said. "We went ahead with the procedure. That's crazy. That's not in the best interest of patient care, and taking [prior authorizations] too far. There should be a track record with the technology that's available today. We know that, ultimately, a certain number of authorizations are going to be approved, so making us go through these extra steps is unnecessary."

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