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Current & Critical

Prior Authorization Chaos is the New Normal for Spine Surgery

By Kim Norton, Vice President of Reimbursement, Simplify Medical

In 2017, the American Medical Association surveyed physicians across all specialties about the amount of time spent by them and their staff on patient prior authorizations. The response was striking. Eighty-six percent of offices reported that their prior authorization activities had increased significantly over the last five years, and the average office was spending two full workdays to receive a prior authorization. 

This trend is impacting spine surgeons likely more than most as a direct result of an increase in both the utilization and cost of spine surgery over the last decade, as well as significant regional variation in both.  Note that while many studies report on cost and utilization, very few link either trend to progress in spine surgery techniques that lead to improved patient outcomes, nor do they generally focus on increased patient access and insurance coverage as contributing factors.

At the same time that commercial health plans began to expand utilization management requirements in order to rein in these increases, the Affordable Care Act was implemented, mandating that commercial health plans must spend less money on administration and more on medical care. Out of this shift arose a focus on "third-party utilization management companies" such as NIA Magellan, eviCore, Turning Point and AIM Specialty Health. The idea was that these companies could conduct prior authorizations in a more standardized manner, and therefore, at a lower cost. 

It is no surprise that spine was one of the first specialties to be “carved out” by many commercial health plans for third-party prior authorization. Exhibit 1 outlines some of the commercial health plans contracting with each of these organizations to date for spine surgery utilization management services. (This is not a complete list and may in fact have changed by the time this article is published.)


Exhibit 1: Third-party Prior Authorization Companies and Commercial Health Plan Partners

 NIA Magellan  eviCore  AIM  Turning Point
 BCBS Florida  BCBS Minnesota*  Anthem BCBS*  Capital BlueCross*
 BCBS Nebraska  Excellus BCBS  Amerihealth  BCBS Tennessee
 BCBS South Carolina  HCSC (BCBS IL, MT, NM, OK, TX)  Independence BlueCross  Fidelis Care
 Harvard Pilgrim  Highmark BCBS*    
 HMSA*  Horizon BCBS    
 Presbyterian Health  Scott & White*    
 ConnectiCare      
 Tufts      
 BlueShield California      


*Read on for discussion of medical policies listed in Exhibit 1.


Speaking with various spine surgeons about this trend showed that their experience to date is as expected—prior authorizations often take longer to conduct, and cases are scrutinized to a much greater degree, requiring more interaction from surgeons to explain why a specific surgery was chosen, or why a particular patient may need more or less surgery than imaging indicates. In fact, many of these companies require radiology images as part of the review process, thereby putting radiologists who are employed by or contracted with the companies in the position of reviewing and denying cases.

As challenging as these reviews are, the fact that these organizations have also established medical coverage policies of their own adds another layer of chaos to this situation. Beyond the content of these policies, which vary in terms of being more or less restrictive by procedure than the respective health plan policies themselves, is the fact that surgeon offices may not be aware of which policy to follow for medical necessity criteria. This situation is created by two confounding issues: 1) Self-insured employer groups using a health plan as a third-party administrator can opt out of the use of the prior authorization companies, including for their policies, and 2) Some health plans have retired their policies, opting to follow the third-party authorization company policies instead.

To illustrate this, a few real examples are outlined below:

As noted in Exhibit 1, NIA Magellan is contracted with BCBS South Carolina. NIA Magellan has its own spine policies, but BCBS South Carolina chooses to continue to use its own medical policies. This is likely to create confusion about which policy should be followed in that market.

In contrast, AIM is contracted with Anthem, and Anthem has decided to retire its own medical policies to follow AIM’s policies. This is true of all of the asterisked health plans in Exhibit 1. The confusion here is that many surgeons may not know that previous policies have been retired when they contact the plan to prior authorize a surgery, and often the new policies have different criteria for medical necessity. Clearly the onus is on the surgeon offices to keep track of policy criteria by health plan and third-party authorization companies.

BCBS Tennessee uses Turning Point for its spine utilization management services and follows Turning Point’s policies for most spine surgery. However, despite the fact that Turning Point has a positive policy for lumbar arthroplasty (for example), BCBS Tennessee has carved out lumbar arthroplasty from Turning Point’s policies and falls back on its own negative coverage policy for this procedure.

Similarly, Blue Shield of California uses NIA Magellan for its spine utilization management services and follows Blue Shield’s policies for most spine surgeries. Despite the fact that NIA Magellan has a negative coverage policy for lumbar arthroplasty, Blue Shield has carved out lumbar arthroplasty from NIA Magellan’s policies and falls back on its own positive policy for this procedure, in this case due to a class-action lawsuit settlement.

This trend is likely to continue, with more health plans contracting with third-party authorization companies, and more third-party authorization companies launching over time. The following are recommendations for both spine surgeons, as well as for the medical technology industry.

Spine Surgeons Industry
  • Track policies for both health plans and third-party authorization companies and share any changes with industry
  • As much as possible, integrate policy criteria and patient indications into electronic medical systems
  • Provide feedback directly to the health plans/third-party authorization companies and consider becoming a reviewer for either or both
  • Develop policy trackers for spine surgeons and keep offices updated on these trends on a timely basis
  • Monitor changes in policy criteria and contact health plans/third-party authorization companies about any inappropriate criteria
  • Advocate for changes to the prior authorization system in general through regional and national trade associations


In a follow-up article, I’ll examine further challenges with prior authorization and internal and external appeals, and the ways that this new normal is impacting patient access to spine surgery in particular.

 

Kim Norton, Vice President of Reimbursement, Simplify Medical and Reimbursement Consultant, has worked in medical device reimbursement, payor relations and market access for over 25 years. Her career spans venture-backed start-up companies, mid-sized and large device companies, and roles in consulting. Ms. Norton has worked across the spectrum of health plans, from CMS to commercial plans to Workers Compensation and has primarily focused on implantable Class III devices.