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Janz TA, Khan NS, Dhanda AK, Takashima M, Wu AW, Tang DM, Higgins TS, Ramanathan M, Ahmed OG. Multi-Institutional Analysis of Insurance Denial Patterns Within Rhinology. Am J Rhinol Allergy 2024; 38:218-222. [PMID: 38544439 DOI: 10.1177/19458924241242856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2024]
Abstract
BACKGROUND Obtaining insurance approval is a necessary component of healthcare in the United States and denials of these claims have been estimated to result in a loss of 3% to 5% of revenue. OBJECTIVE Examine the trends in insurance denials for rhinological procedures. METHODS A retrospective review of deidentified financial data of patients who were treated by participating physicians across 3 institutions from January 1, 2021, to June 30, 2023. The data was queried for rhinological and non-rhinological procedures via CPT codes. Cumulative insurance denials were calculated and stratified by procedure and insurance type. Write-offs were dollar amounts associated with final denials. RESULTS A sample of 102,984 procedures and visits revealed a final denial rate between 2.2% and 2.9% across institutions (p = .72). The top three rhinological procedures for final write-offs were: nasal endoscopy (16.24%, $111,836.87), nasal debridement or polypectomy (6.48%, $79,457.51), and destruction of intranasal lesion (2.11%, $56,932.20). The write-off percentage for each procedure was highest among commercial insurance payers as opposed to Medicare or Medicaid. CONCLUSION Final denial rates of rhinology procedures ranged between 2% and 3%. Common procedures such as nasal endoscopy and nasal debridement are among the highest written-off procedures. Insurance denials can lead to notable revenue loss. Rhinology practices must continue to remain knowledgeable of the changes and effects of insurance reimbursement on their practice.
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Affiliation(s)
- Tyler A Janz
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Medical Branch, Galveston, TX, USA
| | - Najm S Khan
- Department of Otolaryngology-Head and Neck Surgery, Houston Methodist, Houston, TX, USA
| | - Aatin K Dhanda
- Department of Otolaryngology-Head and Neck Surgery, Houston Methodist, Houston, TX, USA
| | - Masayoshi Takashima
- Department of Otolaryngology-Head and Neck Surgery, Houston Methodist, Houston, TX, USA
| | - Arthur W Wu
- Department of Otolaryngology-Head and Neck Surgery, Cedars Sinai, Los Angeles, CA, USA
| | - Dennis M Tang
- Department of Otolaryngology-Head and Neck Surgery, Cedars Sinai, Los Angeles, CA, USA
| | - Thomas S Higgins
- Kentuckiana ENT, A Division of ENT Care Centers, Louisville, KY, USA
| | - Murugappan Ramanathan
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Omar G Ahmed
- Department of Otolaryngology-Head and Neck Surgery, Houston Methodist, Houston, TX, USA
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Torabi SJ, Hong EM, Patel RA, Nguyen TV, Huck NA, Khosravi P, Peter Manes R, Kuan EC. How Variable are Patient Comorbidity Profiles Among Practicing Otolaryngologists? Otolaryngol Head Neck Surg 2024. [PMID: 38738928 DOI: 10.1002/ohn.812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Revised: 04/08/2024] [Accepted: 04/19/2024] [Indexed: 05/14/2024]
Abstract
OBJECTIVE To determine whether certain groups of otolaryngologists (ORLs) are treating cohorts of patients with more comorbidities. STUDY DESIGN Cross-sectional population-based analysis. SETTING 2019 Medicare Provider Utilization and Payment Dataset. METHODS Each ORL's average Medicare hierarchical condition category (HCC) risk score, a comorbidity index calculated from a patient's comorbidities, was collected. These were stratified and compared by various physician characteristics, including practice region and rurality, years in practice, gender, subspecialty, and setting (academic vs community). RESULTS Among 8959 ORLs, the mean HCC risk score for Medicare patients was 1.35 ± 0.35. On univariate analysis, ORLs practicing in urban (compared to rural), ORLs in academic settings (compared to community), and early career ORLs all had a patient population with a higher HCC risk score (P < .001 for all). On multivariate analysis controlling for gender, rurality, graduation year, and region, rural setting was associated with decreased odds of having a high-risk patient population (odds ratio: 0.58 [95% confidence interval, CI: 0.48-0.71]; P < .001), while those more recently graduated has an increased risk (2000-2009: 1.41 [1.01-1.96], P = .046; 2010-2015: 2.30 [1.63-3.25], P < .001). In a separate subgroup analysis, subspecialty differences were seen and community setting was associated with decreased odds of having a high-risk patient population (0.36 [0.23-0.55]; P < .001). CONCLUSION There is variability in patient comorbidity profiles among ORLs, with those in urban settings, those more recently graduated, and those in academic settings treating a group with more comorbidities. As the comorbidity burden may increase the cost of practice and complications, these findings may have important implications for health inequity.
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Affiliation(s)
- Sina J Torabi
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine Medical Center, Orange, California, USA
| | - Ellen M Hong
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine Medical Center, Orange, California, USA
| | - Rahul A Patel
- Frank H. Netter MD School of Medicine at Quinnipiac University, North Haven, Connecticut, USA
| | - Theodore V Nguyen
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine Medical Center, Orange, California, USA
| | - Nolan A Huck
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine Medical Center, Orange, California, USA
| | - Pooya Khosravi
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine Medical Center, Orange, California, USA
| | - R Peter Manes
- Department of Surgery (Division of Otolaryngology), Yale School of Medicine, New Haven, Connecticut, USA
| | - Edward C Kuan
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine Medical Center, Orange, California, USA
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Patel RA, Torabi SJ, Kasle DA, Kayastha D, Peter Manes R. Trends in Billing and Medicare Reimbursement for In-Office Cerumen Removal by Otolaryngologists and Other Providers. Ann Otol Rhinol Laryngol 2023; 132:410-416. [PMID: 35894062 DOI: 10.1177/00034894221096980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To analyze trends in billing patterns, Medicare reimbursement, and practice-setting for otolaryngologists (ORLs) and other provider types performing in-office cerumen removal. METHODS This retrospective study included data on Medicare-billing providers from the Medicare Part B: Provider Utilization and Payment Datafiles (2012-2018). Number of providers performing in-office cerumen removal, total sums and medians for Medicare reimbursements and services, and services per patient were gathered along with geographic distributions. RESULTS There have been near linear declines in number of general physicians and other provider types performing cerumen extractions with 42.6% and 40.7% declines, respectively, and near linear growth in number of ORLs and advanced practice providers (APPs) with 9.7% and 51.1% growth, respectively. At the median, general physicians, APPs, and other provider types have been billing for a similar and constant number of cerumen extractions per provider, while ORLs have seen a 10.6% increase. Total Medicare reimbursement to general physicians and other provider types has fallen 45.0% and 32.5%, respectively, and to ORLs and APPs has grown 16.9% and 103.4%, respectively. Compared to non-ORLs, ORLs tend to bill for cerumen extraction out of an urban setting rather than a rural setting (P < .001). CONCLUSIONS General physicians and other provider types are increasingly referring cerumen disimpaction patients to ORL physicians and allowing APPs to perform these procedures, indicating a change in landscape of medical practice among these providers. General physicians may be filling a need in the rural setting, where there are fewer ORLs practicing.
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Affiliation(s)
- Rahul A Patel
- Frank H. Netter M.D. School of Medicine, Quinnipiac University, North Haven, CT, USA.,Department of Surgery (Division of Otolaryngology), Yale University School of Medicine, New Haven, CT, USA
| | - Sina J Torabi
- Department of Surgery (Division of Otolaryngology), Yale University School of Medicine, New Haven, CT, USA.,Department of Otolaryngology-Head and Neck Surgery, University of California Irvine, Irvine, CA, USA
| | - David A Kasle
- Department of Surgery (Division of Otolaryngology), Yale University School of Medicine, New Haven, CT, USA
| | - Darpan Kayastha
- Department of Surgery (Division of Otolaryngology), Yale University School of Medicine, New Haven, CT, USA
| | - R Peter Manes
- Department of Surgery (Division of Otolaryngology), Yale University School of Medicine, New Haven, CT, USA
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Patel RA, Torabi SJ, Kayastha D, Kuan EC, Manes RP. Medicare Utilization and Reimbursement Variation Between Rural and Urban Otolaryngologists. Otolaryngol Head Neck Surg 2023; 168:528-535. [PMID: 35852873 DOI: 10.1177/01945998221113550] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 06/24/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To compare billing practices, reimbursement rates, and patient populations of otolaryngology (ORL) physicians practicing in rural and urban settings. STUDY DESIGN Retrospective cross-sectional study. SETTING Medicare Provider Utilization and Payment Data: Physician and Other Supplier Data. METHODS Medicare-allowed payments, number of services, and number of patients were gathered along with patient population comorbidity statistics, including average hierarchical condition category risk scores. RESULTS In 2019, 92% of the overall total 8959 ORL physicians practiced in an urban setting. These 8243 urban ORL physicians, on average, billed for 51 (interquartile range [IQR], 31-67) unique Healthcare Common Procedure Coding System (HCPCS) codes, cared for 393 (IQR, 172-535) Medicare patients, performed 1761 (IQR, 502-2070) services, and collected $139,957 (IQR, $55,527-$178,479) per provider. In contrast, the 704 rural ORL physicians, on average, billed for a greater number of unique HCPCS codes (59; IQR, 37-77; P < .001), treated more Medicare patients (445; IQR, 242-614; P < .001), and performed more services (2330; IQR, 694-2748; P < .001) but collected about the same per provider ($141,035; IQR, $56,555-$172,864; P = .426). Older age was associated with rural practice (P = .027). Among both urban and rural ORL physicians, the variety and complexity of procedures and patient comorbidity profiles were comparable. CONCLUSION Most ORL physicians practice in large urban settings, a finding potentially related to financial sustainability and career opportunity. With an already small workforce, the aging rural ORL physician population is an identifiable weak point in the otolaryngology specialty that must be addressed with geo-specific recruitment campaigns, rural work incentivization, and the development of career advancement opportunities in rural areas.
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Affiliation(s)
- Rahul A Patel
- Frank H. Netter M.D. School of Medicine at Quinnipiac University, North Haven, Connecticut, USA
- Department of Surgery (Division of Otolaryngology), Yale University School of Medicine, New Haven, Connecticut, USA
| | - Sina J Torabi
- Department of Surgery (Division of Otolaryngology), Yale University School of Medicine, New Haven, Connecticut, USA
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, USA
| | - Darpan Kayastha
- Department of Surgery (Division of Otolaryngology), Yale University School of Medicine, New Haven, Connecticut, USA
| | - Edward C Kuan
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, USA
| | - R Peter Manes
- Department of Surgery (Division of Otolaryngology), Yale University School of Medicine, New Haven, Connecticut, USA
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Johnson CZ, Edelmayer L, Wang TD. Management of the Deviated Caudal Septum. CURRENT OTORHINOLARYNGOLOGY REPORTS 2022. [DOI: 10.1007/s40136-022-00398-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Patel R, Kejner A, McMullen C. Problematic Reporting of Gender Differences in Clinical Productivity Among Otolaryngologists. JAMA Otolaryngol Head Neck Surg 2021; 147:221-222. [PMID: 33300965 DOI: 10.1001/jamaoto.2020.4628] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Dominguez JL, Ederaine SA, Haglin JM, Aragon Sierra AM, Barrs DM, Lott DG. Medicare Reimbursement Trends for Facility Performed Otolaryngology Procedures: 2000-2019. Laryngoscope 2020; 131:496-501. [PMID: 32619309 DOI: 10.1002/lary.28749] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 04/22/2020] [Accepted: 04/28/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVE There is a paucity of data regarding financial trends for procedural reimbursements in otolaryngology. The purpose of this study was to evaluate monetary trends in Medicare reimbursement rates for the 20 most commonly billed otolaryngology procedures from 2000 to 2019. STUDY DESIGN Analysis of physician reimbursement. METHODS The American Academy of Otolaryngology-Head and Neck Surgery database was queried to determine the 20 most performed otolaryngology procedures. Next, the Physician Fee Schedule Look-Up Tool from the Centers for Medicare and Medicaid Services was utilized to assess each of the top 20 most utilized Current Procedural Terminology (CPT) codes in otolaryngology, and reimbursement data was extracted. All monetary data was adjusted for inflation to 2019 U.S. dollars using changes to consumer price index. Average annual and total percentage change in reimbursement were calculated based on adjusted values for all included procedures. RESULTS After adjusting for inflation, the average reimbursement for the total 20 procedures decreased by 37.63% from 2000 to 2019. The greatest single mean decrease was seen in CPT code 61782 for stereotaxis procedures on the skull, meninges, and brain (-59.96%), whereas the smallest mean decrease was in CPT code 30520 for septoplasty (-1.50%). From 2000 to 2019, the adjusted reimbursement rate for the combined procedures decreased by an average of 2.33% each year. CONCLUSION Medicare reimbursement for included procedures has decreased from 2000 to 2019. Increased awareness and consideration of these trends will be important for policy makers, hospitals, and surgeons in order to assure continued access to meaningful otolaryngology care in the United States. LEVEL OF EVIDENCE 4 Laryngoscope, 131:496-501, 2021.
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Affiliation(s)
| | | | - Jack M Haglin
- Mayo Clinic Alix School of Medicine, Scottsdale, Arizona, U.S.A
| | | | - David M Barrs
- Department of Otolaryngology, Mayo Clinic, Phoenix, Arizona, U.S.A
| | - David G Lott
- Department of Otolaryngology, Mayo Clinic, Phoenix, Arizona, U.S.A
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Krouse JH. Highlights from the Current Issue: December 2019. Otolaryngol Head Neck Surg 2020; 161:909-910. [PMID: 31789130 DOI: 10.1177/0194599819884929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- John H Krouse
- School of Medicine, University of Texas Rio Grande Valley, Edinburg, Texas, USA
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