The High Cost of Spinal Surgery - Necessary or Potential Fraud?
The number of spinal surgeries done in the U.S. has increased in a recent 10 year period by 137%. And the national bill for those surgeries has increased by almost 8 times. This trend has not gone unnoticed by payers.
Lumbar spinal fusion surgeries in particular have been focused on as a target for cost savings. There are conflicting reports as to whether these surgeries are always necessary, whether less invasive therapies can be employed before resorting to surgery, or whether spinal fusion achieves desired success rates. There have even been recent news stories of doctors arrested for fraud in connection with performing unnecessary spinal surgery and then billing federal programs.
In response, some payers have changed their coverage policies to restrict lumbar fusion; for example,excluding the procedure if done solely for the diagnosis of degenerative disc disease, or requiring patients to undergo other therapies first. But, doctors and patients have criticized such policies and often advocacy groups are successful in getting them reversed.
There is a meaningful way to determine if spinal surgery costs are an area
of concern in your population.
- First, it is important to find out your top 10 procedures and what those procedures cost.
- If lumbar spinal fusion or arthrodesis is in the top 10, determine how often degenerative disc disease is the only diagnosis for the procedure.
- Establish if there is one provider who is an outlier either in the number of spinal fusion surgeries performed compared to other orthopedic surgeons or in the amount charged.
- Once outliers are determined, further investigation can reveal if the surgeries are meeting medical necessity and whether charges are appropriate.
- Deeper analysis could reveal potentially fraudulent schemes such as illegal kickbacks paid to surgeons.
The Context4 Healthcare Fraud, Waste and Abuse (FWA) Module of FirstPassTM starts with real-time claims analysis during the claim editing and adjudication cycle, while you’re still calculating your claim liability. FirstPass™ contains thousands of rules consisting of millions of editing combinations, many of which are designed to identify potential FWA conditions.
Additionally, the rules include evaluation of billed charges against our proprietary national Usual,Customary & Reasonable (UCR) fee schedule to find claims with charges out of the national norm for a service. These claims are identified and brought to your attention for follow up. As claims are processed through clinical editing, the FirstPass™ FWA Module ensures that claims meet one or more of our potential FWA rules and alerts your processors to the situation so further analysis and investigation can begin.
