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Pre-Operative Tests Drawing Increased Payer Scrutiny, Orthopedic Group Says

By Elaine Goodman (medical/business Reporter)

Friday, December 1, 2017 | 1117 | 0 | 0 min read

Some California surgeons say they are facing an increased number of payer denials for pre-operative testing, a situation that may delay treatment for injured workers or even increase their risk during surgery. In a white paper published last month, the California Orthopaedic Association says that the denials are coming from payers or utilization review organizations even when the surgery itself is approved. “As payers look for more cost savings, COA is anticipating that getting authorization for pre-operative testing will become an increasing problem for surgical patients,” ...

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Comments

Jeffrey Hirsch Dec 1, 2017 06:19 AM

I don't know where you're getting the data or how old it is, but this article is wrong on reimbursement for an EKG by approx. 1000%.

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GARY BRAZINA Dec 2, 2017 07:50 AM

I have had multiple patients with DM or ASCVD who were to have major surgical procedures DENIED pre op medical clearance! Delayed or cancelled surgery as this "falls below the standard of care" and surgical center regulations.

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Chris Siegert Dec 6, 2017 08:44 AM

As an adjuster for an insurance carrier, I don't see any net savings in paying for UR and IMR instead of just authorizing the requested pre-operative testing. Not authorizing the testing will likely delay surgery and delay getting the injured worker to MMI. This results in increased periods of temporary disability and delays return to work. Clearly this type of hyperactive UR does not benefit the injured worker or the employer. I'd like to know which type of "payers" are doing this and why this is being done because it makes no sense to me. Are we talking about insurance carriers or TPAs? Is this UR being requested by people who focus strictly on medical costs or people who look at the total cost of a claim? Of course some testing might not be necessary but this sounds like a systemic problem better addressed by educating providers and not by submitting everything through the UR process.

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