Insurance company authorization processes need reform, physicians say

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ASC leaders are often frustrated over their interactions with insurance companies. Anthony Romeo, MD, executive vice president of the Musculoskeletal Institute of Duly Health and Care in Elmhurst, Ill., and Alok Sharan, MD, director of spine and orthopedics at Matawan-based NJ Spine and Wellness and originator of the awake spinal fusion procedure, told Becker's ASC Review Podcast at the August Orthopedic, Spine and ASC virtual event that authorizations for procedures should be at least standardized, if not fully automated.

Note: This is an edited excerpt. Listen to the full podcast episode here.

Question: When you talk about prior authorization issues, should there be a technology that automates the process?

Dr. Romeo: I actually believe it is automated, and it's automated against the approval process. That's why I think the government's going to come down when they actually see behind the curtain what's going on. There's just no way that they can deny this many cases upfront and then turn around and say, "Okay, they're authorized."

Dr. Sharan: We're in the process right now of going through all the criteria for authorization for the various spine surgeries we do. Hopefully we'll turn this into a paper, but it's amazing to me that there's variability between what one insurance company thinks qualifies for lumbar fusion versus another. ...

Why is it possible that Aetna is saying, "This patient does not qualify for surgery," but then when they have UnitedHealthcare, they do qualify for surgery? … I remember in November and December, a patient's insurance did not authorize them to have a spinal fusion, but when they switched to a new insurance company in January, they did. What changed in that month, that they were able to qualify for spine surgery? 

It's not based on science, and in medicine, we're based on science. As doctors, we hold ourselves to that higher standard. So why is it that there's so much variability in criteria and who qualifies for what type of surgery? That just doesn't make sense. 

AR: When there's that much variability, we know there's tremendous room for improvement, because there's not that much variability in making the decision on who's the right patient for surgery. ...

There has to be a way for a clear thought to come out and say, Let's have a guaranteed criteria. Once you meet that, you'll be authorized, and it should be automated. There's no reason why this has to go through so much peer-to-peer review. I think we have a long way to go, but I believe we'll get there because I believe our IT systems are getting sophisticated enough to make that happen. 

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