09/09/2010
Spinal procedure pre-authorization
We're implementing pre-authorization for select spinal procedures beginning in fall 2010 with the aims of reducing escalating health care costs and improving the quality of care our members receive.
Spinal fusions represent a significant cost and quality-of-care issue for our members. Spinal fusions for back and neck pain accounted for 1.4% of our total expenses in 2008, totaling over $90 million. Spinal fusions are also associated with low efficacy and high rates of complication. The 2010 Commercial Summary of Cost Opportunity benchmarking study performed by our Actuarial department in August 2009 showed these surgeries to be a leading cause of potentially avoidable inpatient admissions.
Pre-authorization for spinal procedures will focus on three areas: vertebroplasty, kyphoplasty and decompression/laminactomy. Efforts will be focused on pre- and post-service review for medical necessity of these procedure categories. We expect that this program may save $9 million in 2011 by reducing unnecessary spinal procedures.
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