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Low payments for excision surgery frustrate physicians, patients

Low payments for excision surgery frustrate physicians, patients

BY ALICIA GALLEGOS

As Jeff Arrington, MD, became known for performing advanced endometriosis excisions, patients from across the country and beyond the United States began flooding his Ogden, Utah, practice. To accommodate the influx, Dr. Arrington gave up practicing obstetrics and general gynecology and began referring more common gynecologic procedures to his partners so he would be more available for endometriosis patients.

However, it soon became clear that payment for the procedures he was performing would not be enough to keep his practice afloat.


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Perspectives on Endometriosis Management


"I quickly discovered that, for the first 10-11 years, I had been supplementing my practice’s revenue with obstetrics and simple gynecologic surgeries," Dr. Arrington said in an interview. "Once I had to give those up, I discovered that the current reimbursement for complex endometriosis surgeries was insufficient to support a practice. Spending 1-6 hours on a case that a general gynecologist would spend 20-60 minutes on, and [being paid] at the same rate, does not allow enough time in a week to perform enough surgery to pay the bills."

With the support of his multispecialty group, Dr. Arrington approached insurance companies in the hope of creating a separate contract for complicated endometriosis surgeries. Only one company agreed to increase its payment for the surgery. Another company agreed to increase payment as it deemed appropriate after reviewing each operative report. The remainder of insurers expressed no interest, Dr. Arrington said.

He was left with two options: either limit his endometriosis patients and deliver babies again or drop insurance contracts and become an out-of-network provider. In March 2017, Dr. Arrington left his multispecialty group to start his own practice as an out-of-network provider.

"Going out of network was an extremely difficult decision," he said. “It is risky from a practice standpoint and affects not only my patients but also my wife and children. There is worry that this may not work and we will be required to move to another established endometriosis specialty clinic. In short, we were left with no other choice. I clearly could not continue to function on a monthly deficit."

Similar challenges are playing out in practices across the country as surgeons try to manage the relatively low insurance payments for certain complex endometriosis-related surgeries, as well as the often time–consuming paperwork demands that come with seeking appropriate payments and coverage for patients.

While the majority of insurers pay for the "peeking-in" part of the procedure – laparoscopy – most consider excision surgery to be experimental or investigational, said Tamer Seckin, MD, cofounder and medical director of the Endometriosis Foundation of America. Because of this classification, insurance companies do not consider excision itself a treatment for endometriosis, and they do not adequately pay for the surgery, he said.

"The most common challenge is getting the insurance companies to recognize that the extent of laparoscopic deep excision surgery – the gold standard for treating endometriosis – can vary from patient to patient depending on the stage of the disease," Dr. Seckin said in an interview. "They do not recognize the value of endometriosis excision surgeries and, instead, ignore the fact that the surgery is necessary."

A spokeswoman for America's Health Insurance Plans (AHIP) would not comment specifically on coverage for endometriosis excision surgery. Health plans generally have individual policies regarding how they handle such treatments, said Kristine Grow, senior vice president of communication for AHIP.

"Typically, they evaluate requests for new treatments on a case-by-case basis in the context of an expert review of all available evidence to make a coverage determination," she said in an interview.

Specific codes needed

The absence of a specific billing code for endometriosis excision contributes significantly to poor payment for the procedure, surgeons said. Currently, excision is generally billed under CPT code 58662, which refers to the destruction or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method.

This means that insurers view a full and complex excision of endometriosis as comparable to a superficial ablation procedure, said Ken Sinervo, MD, medical director for the Center for Endometriosis Care in Atlanta, which operates on an out-of-network basis.

"There's a huge difference between ablating something and excising something," Dr. Sinervo said in an interview. "With ablation, you can use many different forms of energy, most commonly cautery or laser vaporization. Unfortunately, those have about a 60%-80% chance of recurrence. Excision is a much more labor intensive approach to completely removing all of the disease. What might take me 10 minutes to ablate could take several hours to excise."

Existing CPT terminology also does not take into account the advanced skill of a surgeon performing the excision, added Dr. Arrington. A general gynecologist rarely spends more than 60 minutes on an endometriosis case, he said. If the disease is advanced beyond their skill level to treat, general gynecologists often try to separate some adhesions and either biopsy or superficially burn or laser some lesions, leaving the bulk of the disease untreated, he said.

"A surgeon trained with a goal of full excision has the skill and patience to separate all the adhesions created by the endometriosis and then fully excise the disease regardless of surrounding organs or invasion into other organs – in essence, taking the time to remove all the disease that general gynecologists deem ‘too risky' to remove," Dr. Arrington said. "These two scenarios are considered equal in terms of existing CPT terminology and insurance reimbursements."

Appeals process

At the Center for Endometriosis Care in Atlanta, staff members work with patients to minimize their out-of-pocket costs and also negotiate with insurers regarding coverage of procedures, said Heather C. Guidone, the center’s surgical program director.

Center staff conduct insurance preauthorizations, research patients' benefits, process as much paperwork as possible upfront, and file claims with insurers, Ms. Guidone said. They also send appeal letters if patients are initially rejected for coverage and issue letters of medical necessity, if needed.

"We offer any assistance that they need throughout the process of care and thereafter," she said in an interview. "We really try to help maximize their benefits from their coverage. This helps not only educate the insurance company, but it helps advocate for the patient."

Dr. Seckin and his practice staff in New York City make similar efforts. They routinely advise patients to call their insurance carrier to discuss their diagnosis and recommended treatment.

"We encourage them to have a direct relationship with their insurance company and not be afraid to ask questions," Dr. Seckin said. "We provide whatever supporting documentation is requested, and, in many cases, I write letters on behalf of my patients asking that the insurance company revisit their case."

In some cases, insurers do change course and cover the procedure or surgery, Ms. Guidone said, but it may take several appeals.

"I am encouraged every time I see an insurance company recognize that, 'Yes, this was an incredible increased degree of difficulty.' 'Yes, this couldn’t have been done at the local level.’ ‘Yes, we understand that endometriosis is a specialty disease that requires specialty care.’ I’m always heartened by that. I just wish it was on a broader scale," she said.

Advocating for broader coverage

In order to improve the insurance landscape for physicians and patients, excision surgery needs to be more widely recognized as the optimal way to treat endometriosis, Dr. Sinervo said. This includes more education for gynecologists about excision and broader support for the procedure by the American College of Obstetricians and Gynecologists (ACOG).

"It is very important that we try to train gynecologists to know what the most effective surgical treatment is," he said. "But there's a lot of resistance in the mainstream, with the American College, who aren't that interested in trying to demonstrate that excision is best way to treat [the disease]."

ACOG recommends a range of treatments for endometriosis, depending on the specific case. In a Practice Bulletin issued in 2010 and reaffirmed in 2016, ACOG noted that there was Level A evidence that "excision of an endometrioma is superior to simple drainage and ablation of the cyst wall" [Obstet Gynecol. 2010 Jul;116[1]:223-36] .

In addition to ACOG's development of a broader understanding of excision, Dr. Seckin would like to see it advocate for specific excision surgery CPT and ICD-9 codes.

"Much like cancer, endometriosis is classified into stages, and they vary depending on location of the disease, extent, depth of endometriosis implants, presence and size of ovarian endometriomas, and the presence and severity of adhesions," he said. "Once there are codes, then insurers need to increase the level they pay for each code. Excision surgery is as difficult, if not at times more challenging, than some cancer surgeries that get reimbursed at a much higher rate."

A spokesperson for ACOG said that, over the years, it has worked diligently with representatives of the American Association of Gynecologic Laparoscopists to develop laparoscopic codes specifically for endometriosis surgery. For example, a new code proposal for laparoscopic excision of deep pelvic visceral lesions was submitted to the CPT Editorial Panel in February 2005, according to the ACOG coding department. That proposal was rejected by the panel, which concluded that "existing codes could be modified to reflect this service (e.g., 58662 with modifier –22)," according to ACOG.

"Attempts to obtain support from our colleagues in general surgery have been frustrating and challenging," the ACOG spokesperson said. "Without their support and buy in, we have been unable to get codes accepted by the [American Medical Association] CPT Editorial Panel. This has been an ongoing process, and we are currently attempting to engage with the American College of Surgeons to propose a set of codes."
Meanwhile, Dr. Arrington said he hopes his decision to move out of network will pay off. He worries that patients may be discouraged by the added hassle and expense of being treated by an out-of-network physician and will seek care elsewhere.

"My biggest fear with moving out of network is that I will lose the young patients," he said. "I truly believe that, if we don't make these women suffer for years before they have appropriate surgical excision, we could prevent most cases of advanced-stage endometriosis that put patients at risk for opioid dependency, depression, and infertility. This disease destroys lives largely because it is inappropriately managed."

Alicia Gallegos is a writer for Ob.Gyn. News

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