This article is more than 5 years old. Information may no longer be current.
Ohio implements new rule for reimbursement of back surgery in workers’ compensation patients
Click Here to Manage Email Alerts
The Ohio Bureau of Workers’ Compensation created a new rule, effective Jan. 1, 2018, for reimbursement of lumbar fusion surgery for the treatment of injuries sustained in the workplace.
According to the rule (4123-6-32), the move is not an effort to substitute a surgeon’s responsibility to make the right decision for the treatment of injured workers. Providers may be subject to peer review by the bureau of workers’ compensation stakeholders’ health care quality assurance advisory committee, if they do not comply with the requirements of the rule.
NASS comments
Daniel K. Resnick, MD, president of the North American Spine Society (NASS), told Healio.com/Orthopedics in a statement, “Due to the current opioid epidemic, it is worthwhile to look at ways we can curb opioid usage and the inappropriate use of lumbar fusion, but this new policy is naïve. It will do little to prevent the use of fusion in patients with questionable indications and will create administrative barriers and increased costs for the appropriate utilization of fusion in patients who would benefit. Keeping these patients off of work for an extra 2 months while employing therapies that have been shown to be less effective will not improve patient outcomes or cost-effectiveness.”
Provider, patient responsibilities
“[It] appears that the [Ohio Bureau of Workers’ Compensation] OBWC seeks not only to inform patients undergoing fusion of the inherent risks of the procedure and consequences of their choice, but also to present the responsibilities of the providers of that care,” Joseph D. Smucker, MD, from the Indiana Spine Group, told Healio.com/Orthopedics. “Evidence-based statements for treatment of orthopedic and spinal conditions have been previously published by national organizations, such as NASS.”
He added, “At present, it is not uncommon for patients covered by commercial insurance and seeking similar care to meet a specific threshold of preoperative and/or non-surgical care prior to approval of a surgical procedure from an insurance perspective. Ohio’s new rule takes these positions further with respect to both provider and patient responsibilities, as well as surgical preparation in this specific population of patients.”
The rule offers prerequisites to the consideration of lumbar fusion surgery that include conservative treatment, that the operating surgeon who requests the procedure must have evaluated the injured worker at least twice before requesting surgery and that the injured worker undergoes comprehensive evaluation. The rule also includes guidelines for authorization for lumbar fusion surgery in cases in which the injured worker has no prior history of lumbar surgery and for cases that do have a history of prior surgery.
The Ohio rule includes guidelines for follow-up after lumbar fusion surgery which include that the physician or operating surgeon follow the injured worker until the patient has “reached maximum medical improvement for the allowed lumbar conditions.”
“Now more than ever, the Ohio rule reminds us that it is incumbent upon health care professionals not only to assist patients in a path toward appropriate care, but also to actively participate at the state and national levels as advocates for our patients,” Smucker said. – by Monica Jaramillo
Disclosure: Smucker reports no relevant financial disclosures.
Resnick reports no relevant financial disclosures.
Reference:
www.bwc.ohio.gov/downloads/blankpdf/4123-6-32N(1-1-18).pdf
Editor's note: This article was updated on Jan. 29 with comments from Resnick.