Review good for spinal patients

One positive aspect of the Obamacare law rests with the new Medicare program called the Medicare Program for Evaluating Payment Patterns Electronic Reporter, or PEPPER. Hospitals throughout this state were made acutely aware of this program when Medicare began reviewing spinal surgeries and exposed a high error rate due to lack of medical necessity documentation resulting in a reduction in payments.

According to data published on the Palmetto GBA website, a prepayment review of 251 claims in North Carolina, Virginia and West Virginia led to 168 claims either completely or partially denied. The total reviewed was $6,356,890, and $4,141,771 was denied, resulting in a charge denial rate of 65 percent. Imagine the shock wave when payment for 65 percent of fusions was denied! Finally, there appears to be some sanity in the medical spine industry, at least by the payors at CMS.

On average, Medicare pays these hospitals about $31,000 for each spinal fusion, and surgeons about $12,000. The next round of the PEPPER guidelines has flagged these short-term, acute-care hospitals that are performing more than their “fair share” of spinal fusion procedures. CMS will focus on the medical necessity and, because most spinal-fusion procedures are performed on an inpatient basis to qualify for Medicare reimbursement, hospitals will have to evaluate whether patients need them at all. No longer can hospitals have an open-door policy to any surgeon who wants to fill a bed.

Since 1994, many comparative studies have confirmed the inefficiency of medical spine care, such as the AHCPR’s conclusion only one in 100 cases of acute low back pain requires surgery. This agency also failed to recommend narcotic painkillers, epidural steroid injections, standard physical therapy, or the majority of medical methods routinely used by the medical spine industry for spine-related disorders.

The North American Spine Society, or NASS, which once worked to diminish these results to policy makers from the most extensive meta-analysis ever performed, is now changing its tune. NASS is now recommending spinal fusion as the last resort and spinal manipulative therapy as the first choice. Chiropractic care physicians provide 96 percent of all spinal manipulative therapy and retain the most trained spinal specialists to offer this form of care.

Byron R. Folwell, D.C.