Here are six key updates for spine surgeons from CMS and private insurers since July 1.
1. Effective Sept. 1, UnitedHealthcare began requiring prior authorization for physical therapy, occupational therapy, speech therapy and Medicare-covered chiropractic services delivered in multidisciplinary offices and outpatient hospital settings.
2. On Oct. 1, UnitedHealthcare will launch a national gold-card program for providers that consistently adhere to evidence-based guidelines to bypass prior authorizations for some medical services. UnitedHealthcare released a list of gold card-eligible services Sept. 1 and began the program Oct. 1. The program applies to commercial, individual exchange, Medicare Advantage and community plans.
3. On Aug. 15, the U.S. government announced negotiated prices for 10 medications under President Joe Biden's Inflation Reduction Act. Analysts are now predicting that one of the medications that could see negotiations in 2027 is Novo Nordisk's Ozempic for diabetes.
4. CMS proposed the Transforming Episode Accountability Model, a new five-year, episode-based payment model affecting orthopedics and spine, in April and the final rule is expected to drop soon. The proposal requires select acute care hospitals to coordinate care for patients in the traditional Medicare model undergoing surgical procedures and assume responsibility for the cost and quality of care for the first 30 days after leaving the hospital. Lower joint replacements, spinal fusions, and surgical hip femur fracture treatment are included in the proposed model.
5. CMS' proposed 2025 ASC and hospital outpatient prospective payment system rule includes the removal of the MRI lumbar spine for low back pain. CMS suggested the removal starting in the 2025 reporting period, citing studies that "performance or improvement on the measure did not result in better patient outcomes," the July 10 proposal said.
6. CMS on July 10 shared its proposed changes to the 2025 physician fee schedule, and it includes a proposed 2.8% conversion factor decrease from 2024. Some spine surgeons expressed concern about the decision.