A Cross-sectional Analysis of Insurance Coverage of Extremity Contouring After Massive Weight Loss.

INTRODUCTION: After bariatric surgery, patients often experience redundant skin in the upper arms and medial thighs as sequelae of massive weight loss. Insurance companies have unpredictable criteria to determine the medical necessity of brachioplasty and thighplasty, which are often ascribed as cosmetic procedures. We evaluated current insurance coverage and characterized policy criteria for extremity contouring in the postbariatric population. METHODS: We conducted a cross-sectional analysis of insurance policies for coverage of brachioplasty and thighplasty in January 2019. Insurance companies were selected based on their state enrolment data and market share. A web-based search and direct calls were conducted to identify policies. A comprehensive list of standard criteria was compiled based on the policies that offered coverage. RESULTS: Of the 56 insurance companies assessed, half did not provide coverage for either procedure (n = 28). No single criterion featured universally across brachioplasty and thighplasty policies. Functional impairment was the most commonly cited condition for preapproval of brachioplasty and/or thighplasty (94%). Conversely, minimum weight loss was the least frequent criterion within the insurance policies (6%). Only 5% of the insurance companies (n = 3) would consider coverage of liposuction-assisted lipectomy as a modality for brachioplasty or thighplasty. CONCLUSIONS: We propose a comprehensive list of reporting recommendations to help optimize authorization of extremity contouring in the postbariatric population. There is great intercompany variation in preapproval criteria for brachioplasty and thighplasty, illustrating an absence of established recommendations or guidelines. High-level evidence and investigations are needed to ascertain validity of the limited coverage criteria in current use.

Introducing a Clinical Documentation Specialist to Improve Coding and Collectability on a Surgical Service.

INTRODUCTION: Inadequate electronic medical record (EMR) documentation remains a significant source of revenue loss. The Department of Surgery in a trauma and tertiary care teaching hospital developed a revenue optimization initiative for inpatients on general, vascular, and trauma surgery and surgical intensive care unit services to enhance clinical documentation and increase revenue capture. METHODS: Clinical documentation management program included six trained clinical documentation specialists (CDSs), five physician assistants (PAs), directors of health information management (HIM), and two surgical champions. Lean methodology was applied to develop a coding and documentation program wherein trained CDS polled ICD-10 codes in the surgical EMR for accuracy in diagnoses documentation. An opportunity for improved documentation prompted query generation for a specially trained PA review. Physician assistant adjusted EMR documentation according to query to more accurately describe high impact diagnoses. Outcomes included PA query response rate, potential revenue opportunities, validated revenue gains, and missed revenue opportunity. RESULTS: Twelve thousand EMRs were queried in the study interval. $2,206,620.16 in validated revenues were realized. Interestingly, we identified $1,792,591.91 in potential opportunities and $65,097.30 in lost opportunities. Query response rate increased from 17% to 94.7%. CONCLUSIONS: The authors demonstrate a concentrated Coding and Documentation Program involving CDS, and Surgical PAs results in significant revenue gains for an inpatient surgery service in a public hospital.

Economic evaluation of endoscopic sinus surgery versus continued medical therapy for refractory chronic rhinosinusitis.

OBJECTIVES/HYPOTHESIS: To evaluate the long-term cost-effectiveness of endoscopic sinus surgery (ESS) compared to continued medical therapy for patients with refractory chronic rhinosinusitis (CRS). STUDY DESIGN: Cohort-style Markov decision-tree economic evaluation. METHODS: The economic perspective was the U.S. third-party payer with a 30-year time horizon. The two comparative treatment strategies were: 1) ESS, followed by appropriate postoperative medical therapy; and 2) continued medical therapy alone. Primary outcome was the incremental cost per quality-adjusted life year (QALY). Costs were discounted at a rate of 3.5% in the reference case. Multiple sensitivity analyses were performed, including differing time-horizons, discounting scenarios, and a probabilistic sensitivity analysis (PSA). RESULTS: The reference case demonstrated that the ESS strategy cost a total of $48,838.38 and produced a total of 20.50 QALYs. The medical therapy alone strategy cost a total of $28,948.98 and produced a total of 17.13 QALYs. The incremental cost effectiveness ratio for ESS versus medical therapy alone is $5,901.90 per QALY. The cost-effectiveness acceptability curve from the PSA demonstrated that there is a 74% certainty that the ESS strategy is the most cost-effective decision for any willingness to pay a threshold greater than $25,000. The time-horizon analysis suggests that ESS becomes the cost-effective intervention within the third year after surgery. CONCLUSION: Results from this study suggest that employing an ESS treatment strategy is the most cost-effective intervention compared to continued medical therapy alone for the long-term management of patients with refractory CRS.

Do market fees differ from relative value scale fees? Examining surgeon payments in New Zealand.

OBJECTIVES: Health funders face the challenge of determining the appropriate level of surgeon fees in fee-for-service schemes.  A resource-based relative value scale (RBRVS) attempts to identify the fees that would exist in a competitive market.  Private insurance providers in New Zealand do not use a RBRVS but rather rely on a market.  We explore the extent to which private surgeon fees in New Zealand are consistent with fees that would be generated by a RBRVS. METHODS: Data on 155,290 surgical procedures from 2004-06 were provided by New Zealand's largest private health insurer.  314 procedure codes were matched to the Australian Ministry of Health and Ageing's RBRVS. A random effects model determined predicted surgeon reimbursements based on the RBRVS, the location and the year. Procedure volume and specialty were explored as potential sources of deviations. RESULTS: The RBRVS, location and year explain 79% of the variation in surgeon fees. After accounting for the RBRVS, location and year, no statistical differences were found between five out of the seven specialties, but higher volume procedures were associated with lower fees. There was some evidence that the model explained less variation in lower volume procedures. CONCLUSIONS: Surgical fees were generally consistent with those predicted by the RBRVS. However, the fees for high volume procedures were relatively lower than predicted while the fees for low volume procedures appeared more variable. The findings are consistent with the hypothesis that market forces lowered prices for procedures with higher volumes. This has implications for how health funders might determine private surgical fees, especially in mixed public-private systems.

Emergency room coverage: an evolving crisis.

Historically, a newly graduated plastic surgeon in the United States could build a practice from his or her emergency room coverage. The historical cliche was for the surgeon to be affable, able, and available, and from that basis one's practice would grow. Emergency room exposure was an avenue for starting a practice, developing recognition, and, after that, building a referral pattern. Recently, the cross-shifting influence of management care, rising malpractice insurance costs, and risk ratio are changing this cliche to a crisis. An evaluation of a 2 1/2-year exposure to emergency room coverage has revealed a completely different profile. A total of 300 patient visits resulting in 69 surgical operations were evaluated for insurance and remuneration history. The findings indicated a significant remuneration dilemma for emergency room coverage. Interestingly, a remuneration problem exists in a market different from what one would expect. In this study, a sample from a suburban hospital, rather than an inner-city university hospital, is the greater problem.

[Cost analysis of peritrochanteric fractures according to types of surgical treatment and progressive care from the viewpoint of financial providers]. / Trochantertáji törések ellátásának költségvizsgálata a mútéti eljárások és a progresszív ellátási szintek szerint finanszírozói szemszögból.

AIM: The aim of this study to calculate the health insurance cost of treatment of patients with pertrochanter fracture of femur from the first hospital admission for 18 months follow up period according to different surgical methods and progressivity levels. DATA AND METHODS: Recruitment criteria were: 1) all patients with a hip fracture in 2000 defined by the International Classification of Disease (ICD) as "S7210"; 2) working age between 18-60 and 3) first admission to surgical unit, and had an operation. The cost analyses include the cost of acute and chronic in-patient care, outpatient care and sick pay. RESULTS: The total costs were the highest in case of those types of operations with lower cost of prothesis device and lower load stability (Ender 588.000 Ft, fix angled plate 534.000 Ft) because of the higher sick-pay costs. The total costs were the lowest in case of those types of operations with higher cost of prothesis device and higher load stability (Gamma 512.000 Ft, DHS 465.000 Ft) because of the lower sick-pay costs. The gain in recovery time with the 3-4 months shorter disability period can be seen in case of operations with higher load stability. The average length of stay decreases from 15-17 days to 9-11 along progressivity levels. CONCLUSION: With the application of load stable prothesis device the total health insurance costs were the lowest at the universities and national institute while these costs proved to be higher.

Hysterectomy charges: geographic variations United States, 1994.

During 1994 Metropolitan Life Insurance Company claims by group health insureds and their dependents for a vaginal hysterectomy averaged $10,500, for an abdominal hysterectomy (laparotomy), $12,440, and for a laparoscopically assisted vaginal hysterectomy (LAVH), $13,840. The distributions of the three surgeries varied by geographic area and state. The East South Central states had the lowest average total charge for each procedure whereas the highest charge for a laparotomy was reported in the Middle Atlantic states; the highest vaginal hysterectomy charge was in the Pacific area, and LAVH average total charge was the highest in New England. Of the three surgeries, the vaginal hysterectomy charges varied the most by state-the average charge in Florida was almost twice that in Oklahoma. Laparotomy charges differed by 59 percent between California and Tennessee, where they were 30 percent above and 19 percent below the U.S. norm, respectively. The total charge for the LAVHs varied by 42 percent and was the highest in California and lowest in North Carolina. Three study states, California, Florida and Illinois, were among the four states with the highest average total charges for each form of hysterectomy. Physicians' fees accounted for 41 percent of vaginal hysterectomy charges, 37 percent of the laparotomy total charges, and 34 percent of the LAVH charges. Of the laparotomies, the physicians' fees differed by 132 percent between the highest in New York and the lowest in Tennessee. For the country as a whole, the average length of stay was 2.17 days for the LAVHs, 2.54 days for a vaginal hysterectomy and 3.43 days for an abdominal hysterectomy.

[Ambulatory surgery--financing from the viewpoint of health insurance]. / Ambulantes Operieren--Finanzierung aus der Sicht der Krankenkassen.

New regulations, which have been implied by the Health Structure Act, are aiming to improve the coordination between ambulant and in-patient-surgery. In the view of the health insurance scheme, this could be the beginning of a new era in the health care system of Germany. Following a short presentation of these new regulations and of the opportunities to cut down expenses by ambulatory surgery, the author describes the development of ambulatory surgery in the private-practice-setting. He presents the framework for ambulatory surgery in hospitals, which has been created by negotiations on a national level, and he draws future perspectives of ambulatory surgery.

Comparing surgical efficiency in independent practice association HMOS and traditional insurance programs.

This study examines the effect of Independent Practice Association (IPA) HMO membership on hospital total charges, ancillary charges and length of stay (LOS) for surgical patients. Intrahospital comparisons of IPA and traditional insurance patients are made after adjusting for surgical procedure, admission severity of illness, age, sex and year of admission. Our multiple regression model indicates that IPA patients undergoing 12 frequently occurring surgical procedures have lower resource use. Eight (80%) of the 10 study hospitals exhibit a negative IPA beta coefficient for total charges, ancillary charges and LOS. Five (50%) hospitals have statistically significant (p < 0.05) negative coefficients for total charges, while one (10%) hospital has a significant positive coefficient. IPA patients exhibit adjusted total charges that are 6% lower than traditional insurance, ancillary charges that are 4.3% lower, and LOS that is 10% shorter.

Insurance incentives for ambulatory surgery.

This study is an attempt to address both the extent to which surgical procedures on an outpatient basis substitute cost-effectively for inpatient procedures, and whether or not an insurance policy's financial incentives increase the volume of outpatient surgical procedures. In particular, given an insurance product of a given composition: What is the probability that the insured will have surgery? and if a surgery does take place, what is the probability that it will occur in an outpatient setting? Finally, the article assesses the implication of such products on the total cost of care by quantifying the insurance plans along two parameters, the relative user price for outpatient versus inpatient surgery and the absolute price for the inpatient surgery. The results indicate that insurance policies that offer relatively lower out-of-pocket payments for ambulatory surgery do not increase the probability that surgery will be done in the ambulatory setting. However, higher out-of-pocket payments for surgery, regardless of site, do reduce the surgery rate. There are other patient and market characteristics, especially the availability of freestanding surgery firms, that do influence the location of surgery.

[The covering physician system from the viewpoint of the insurance company]. / Das Belegarztsystem aus der Sicht der Versicherer.

The main question is: To whom and according to which regulations does the nonresident physician bill for reimbursement? The analysis brings to evidence, that different answers have to be given for each kind of treatment (outpatient medicine, care in ambulatory settings of hospitals, and inpatient medicine). Moreover, each kind has to be looked at differently with regard to three categories: (1) the patient who pays himself (self payers scheme), (2) the patient who is subject to the social illness insurance, and (3) the one is subject to the compulsory social accident insurance. The whole matter is extremely complex, and thus little understood as well by the nonresident physician as by the patients. Furthermore, economic disparities are apparent when looking at the various social insurance legislations, and when considering the medical tariff of each social insurance scheme. Obviously, the self payer schemes are simple, transparent and thus better understood: The nonresident physician bills to the patient directly, who in term owes payments, regardless whether he is insured or not. This system applies to all non-social insurance schemes, particularly to the private insurance scheme. Yet, the self payers schemes are successful only when State and local governments reduce their subsidies and grants to their own hospitals, and if all medical services are paid on an effective cost basis: in order to give equal chances to all medical services, private and public. Thus, the patients' position would be uprated. At the same token, the nonresident physicians would have firmer chances which in turn would mean an enormous advantage to their patients since they could be treated by one and the same physician before, during and after their hospital stays.

An access-oriented negotiated fee schedule. The Caterpillar experience.

This paper describes the system used by Caterpillar Corporation (CAT) in Peoria, Illinois, to reimburse surgeons. The CAT system assures access for Caterpillar employees and their families to a selection of qualified surgeons, while achieving cost savings through improvements in processing of surgical claims and negotiation of selected fees. CPT-4 codes are recorded for greater accuracy, when indicated, surgical services that have been incorrectly unbundled are rebundled, and the appropriateness of surgical assistant charges is reviewed. A "degree of difficulty" relative value scale (DODRVS) of surgical services is periodically revised as technology changes. The DODRVS multiplied by a regional factor, determined by local market research, establishes the fee that CAT will pay the surgeon. Balance billing is permitted if the patient (1) is informed in advance by the surgeon that the fee will be higher than CAT will pay, and (2) knows that the service can be obtained from other local surgeons who will accept the CAT fee. The goal of the CAT method of surgeon reimbursement is to gain physician support for an access-oriented, market-driven negotiated fee schedule. Compared with a resource-based relative value scale RBRVS) methodology, the CAT system is not formula-driven and depends on physician acceptance.