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J Neurosurg. 2017 Aug;127(2):332-337. doi: 10.3171/2016.5.JNS152135. Epub 2016 Sep 9.

Impact of insurance precertification on neurosurgery practice and health care delivery.

Author information

1
Department of Neurosurgery, LSU Health Shreveport, Louisiana.
2
Harvard University John F. Kennedy School of Government, Cambridge, Massachusetts; and.
3
Department of Surgery, Mayo Graduate School of Medicine, Rochester, Minnesota.

Abstract

OBJECTIVE Insurance preauthorization is used as a third-party tool to reduce health care costs. Given the expansion of managed care, the impact of the insurance preauthorization process in delaying health care delivery warrants investigation through a diversified neurosurgery practice. METHODS Data for 1985 patients were prospectively gathered over a 12-month period from July 1, 2014, until June 30, 2015. Information regarding attending, procedure, procedure type, insurance type, need for insurance approval, number of days for authorization, or insurance denial was obtained. Delay in authorization was defined as any wait period greater than 7 days. Some of the parameters were added retrospectively to enhance this study; hence, the total number of subjects may vary for different variables. RESULTS The most common procedure was back surgery with instrumentation (28%). Most of the patients had commercial insurance (57%) while Medicaid was the least common (1%). Across all neurosurgery procedures, insurance authorization, on average, was delayed 9 days with commercial insurance, 10.7 days with Tricare insurance, 8.5 days with Medicare insurance, 11.5 days with Medicaid, and 14.4 days with workers' compensation. Two percent of all patients were denied insurance preauthorization without any statistical trend or association. Of the 1985 patients, 1045 (52.6%) patients had instrumentation procedures. Independent of insurance type, instrumentation procedures were more likely to have delays in authorization (p = 0.001). Independent of procedure type, patients with Tricare (military) insurance were more likely to have a delay in approval for surgery (p = 0.02). Predictably, Medicare insurance was protective against a delay in surgery (p = 0.001). CONCLUSIONS Choice of insurance provider and instrumentation procedures were independent risk factors for a delay in insurance preauthorization. Neurosurgeons, not just policy makers, must take ownership to analyze, investigate, and interpret these data to deliver the best and most efficient care to our patients.

KEYWORDS:

ACDF = anterior cervical discectomy and fusion; MLR = medical loss ratio; Medicaid; Medicare; health care economics; insurance preauthorization; neurosurgery practice delivery

PMID:
27611204
DOI:
10.3171/2016.5.JNS152135

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