What are the biggest payer problems for orthopedic practices?

Understanding how to navigate payer relationships is critical for orthopedic practices to succeed. Three surgeons spoke to Becker's Spine Review on the biggest challenges they see with payers. 

Question: What is the biggest payer problem in orthopedic practices?

Nitin Khanna, MD. Spine Surgeon and Founder of Spine Care Specialists (Munster, Ind.).​ The pre-certification process is broken. Government intervention is needed that would hold insurance companies accountable for denials of surgery and diagnostic testing. A Department of Justice investigation should expose these business practices when primary care physicians are denying spine surgery through a peer-to-peer call. Premiums continue to rise for employers, and access continues to decrease. 

This is an unsustainable model. Conceptually, a large orthopedic group's size and market dominance should drive contracting. However, this is not always the case. Insurance companies have gotten bolder and more hostile in their approach to providers. This has spurned the entrance of private equity into health care with surprise billing associated with anesthesia, neuromonitoring and emergency medicine, just to name a few. A reasonable rate of reimbursement directly to independent providers would drive cost savings and increase access and quality of care. 

Excerpt from interview published in Beckers Spine on May 3, 2021.