<body><div><img src="https://img.particlenews.com/image.php?type=thumbnail_580x000&amp;url=1WtAFT_1FSMuD6600" alt="https://img.particlenews.com/image.php?url=1WtAFT_1FSMuD6600" width="800" height="600" >An orthopedic practice can obtain prior authorization from a Medicare Advantage plan, perform the procedure and still not know whether the payment will hold.Wilford Gibson, MD, sees a fundamental problem in that sequence.“You usually get a notice or a code that your surgery has been approved, but prior approval is no guarantee of payment,” Dr. Gibson, president of the American Academy of Orthopaedic Surgeons a​​nd partner at Virginia Beach, Va.-based Atlantic Orthopaedic Specialists, told Becker’s. “What are we supposed to do?” That uncertainty is behind AAOS’ support for the Protecting Approved Care Act, bipartisan legislation introduced Sept. 15 by Reps. Greg Landsman, D-Ohio, and Bob Onder, R-Mo. The bill would require Medicare Advantage plans to honor original coverage decisions and establish safeguards against retroactive denials and payment recoupments after care has been delivered. But for Dr. Gibson, clawbacks are part of a larger problem confronting practices. Medicare reimbursement is under pressure. Practice expenses continue to rise. More postoperative work is following patients beyond the hospital as orthopedic care moves outpatient. And even after navigating prior authorization, physicians can face uncertainty over whether they will ultimately be paid. “There’s less money coming in and more money going out,” he said. “That’s not sustainable.”When an approval isn’t really an approvalPrior authorization is supposed to establish whether an insurer will cover a service before it is delivered. The Protecting Approved Care Act targets what can happen afterward.AAOS said Medicare Advantage plans can retroactively deny coverage, reduce payment or seek repayment after procedures that were previously authorized or did not require prior authorization. The organization argues those decisions can leave physicians trying to recover payment for care already delivered and patients facing unexpected financial liability. Dr. Gibson said commercial insurers have used clawbacks for years. Medicare Advantage adds another dimension because physicians are treating Medicare beneficiaries through plans administered by private insurers.For practices, authorization does not eliminate the uncertainty. “Prior approval is no guarantee of payment,” he said. “It’s always unsettling. Are you going to get paid or not?” Patients can be caught in the middle. Dr. Gibson said some Medicare beneficiaries may not fully anticipate the authorization requirements that come with Medicare Advantage. If payment is later reversed, they can face a bill for care they believed was covered. For practices, however, payment certainty is only one part of the equation.The work didn’t disappear — It movedOrthopedic surgery has become substantially more efficient. Hip and knee replacement patients who once spent days in the hospital can increasingly leave the same day or shortly after surgery. But some of the work that used to occur during a hospital stay did not disappear. It moved to physicians and their teams.Practices field postoperative calls, manage medications and monitor patients after discharge. At the same time, Dr. Gibson said expenses including staffing, electronic health records, technology and malpractice coverage continue to rise. AAOS is also pushing back on proposed changes to the 2027 Medicare Physician Fee Schedule that the organization says would reduce work relative value units for total hip, knee and shoulder arthroplasty by about 20%. “We have to make payroll every two weeks,” Dr. Gibson said. “The money that we bring in is what we use to pay our costs before we pay the doctors.”For independent practices, continued pressure eventually forces operational decisions.What practices cut nextDr. Gibson said practices are already considering what they would have to change if reimbursement pressure continues. That could mean reducing staff, eliminating services, closing remote offices to reduce overhead or limiting the number of Medicare patients they accept.Some physicians, he said, are discussing leaving Medicare altogether. AAOS is not advocating for that response, Dr. Gibson emphasized. The organization wants surgeons to remain able to care for Medicare beneficiaries.But practices still have to make the math work. “We may have to lay off employees,” he said. “We may not provide services that we used to provide. We may have to make some pretty significant changes to survive.” Those decisions can become access problems quickly. Dr. Gibson pointed to patients traveling from Virginia’s Eastern Shore to his practice. Some travel significant distances and pay bridge tolls to reach orthopedic care. If practices respond to reimbursement pressure by shrinking their footprints or separating services into additional visits, those patients could face more travel.“You’ve decreased your footprint, closed offices and perhaps reduced the number of Medicare patients you see,” he said.‘Hopefully, make it five years’The pressure is also raising a larger question for orthopedics: what independent practice will look like if the current trajectory continues. Asked how practices should prepare for the Medicare environment five years from now, Dr. Gibson questioned whether some private practices will make it that far.“Hopefully, we make it five years,” he said. “With the trend we’re on and the payment models we have now, I don’t know that private practice is going to survive another five years.”Moving more procedures to ASCs is one potential response, but Dr. Gibson said it is not a universal escape valve. Certificate-of-need laws can restrict physicians’ ability to develop surgery centers in some states. And not every Medicare beneficiary is an appropriate candidate for outpatient surgery. Patients with significant comorbidities may need hospital resources because of anticoagulation management, cardiac conditions or potential postoperative complications.“You still have patients on the far end of that curve who can’t safely be treated in an ambulatory surgery center,” he said.Dr. Gibson worries continued pressure could ultimately contribute to a two-tiered system in which healthier patients can move into lower-cost outpatient settings while medically complex patients have fewer surgeons and sites available to treat them. What comes nextDr. Gibson does not argue for preserving fee-for-service unchanged. He sees an opportunity to rethink value-based care.Orthopedic practices have participated in bundled-payment models that reward physicians for reducing episode costs while maintaining quality. But Dr. Gibson said physician groups need a more direct opportunity to participate in, and benefit from, those savings. One possibility is a more prospective model: Establish the value of an episode of care, build a 30-, 60- or 90-day bundle and give physicians a meaningful role in designing and participating in it.What practices cannot do, he said, is wait 18 months or two years for reconciliation to determine whether they earned shared savings.“The practice may be closed by then.” For now, AAOS wants CMS to pause major 2027 fee-schedule changes and maintain 2026 payment values while physicians and policymakers work toward another approach. Dr. Gibson argues that whatever comes next has to account for something payment models can struggle to capture: what delivering orthopedic care actually requires once policy reaches the OR.“For those of us in the trenches, it’s good to hear about what could be, what should be and what might be,” he said. “But when you’re there with the knife, the saw and the drill, it gets more granular than the data.”The Protecting Approved Care Act addresses one part of that uncertainty by seeking to make an insurer’s original coverage decision stick. For orthopedic practices, that would mean greater certainty that care approved before a procedure will remain covered after it.But Dr. Gibson’s larger concern extends beyond clawbacks. Practices can cut staff. They can consolidate offices. They can shift appropriate cases outpatient or limit Medicare volume. Eventually, there are fewer places left to cut. And at that point, a reimbursement problem becomes an access problem.At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.</div></body>

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An orthopedic practice can obtain prior authorization from a Medicare Advantage plan, perform the procedure and still not know whether the payment will hold. Wilford Gibson, MD, sees a fundamental problem in that sequence. “You usually get a notice or a code that your surgery has been approved, but prior...

AAOS president: ‘Hopefully, we make it five years’

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An orthopedic practice can obtain prior authorization from a Medicare Advantage plan, perform the procedure and still not know whether the payment will hol

AAOS president: ‘Hopefully, we make it five years’

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