Dr. Tollestrup’s addresses why he does not take commercial insurance. The short answer is because his surgeries are so new that there are no appropriate codes for reimbursement. He explains in detail how and why he was forced to drop commercial insurance in his practice.
Transcript:
One question Obviously that my office deals with frequently, and sometimes I get asked by patients is why I don’t accept commercial insurance. At this point, the only insurance that I take is Tri-Care because I always feel like I want to try and take care of the veterans who have sacrificed so much for us. This field of pain-focused peripheral nerve surgery is very new, and there’s very few people that do it. Because of that reason, there’s we have no lobbying group in Washington, DC that can lobby Medicare for appropriate reimbursement for the CPT codes that we have to use.
Just as a way of a quick explanation, any surgeon who does a procedure, there’s a five-digit code called a CPT code that he uses, and it may be one code or maybe multiple codes, depending on how complex or long the procedure is. A monetary amount has been affixed to each one of those codes. So, for example, if an orthopedic surgeon is doing a knee replacement procedure, there’s a code that describes that and has been fairly negotiated to reflect the skill, the expertise, how difficult the surgery is, et cetera, et cetera.
And so that surgeon can hand that code into the insurance company or to Medicare, and they’re going to get a reasonable reimbursement. That doesn’t exist in this field. What we’ve had to do for a long time is just sort of cobble together generic throwaway codes from the back of the neurosurgical section of the CPT code book. And these codes don’t reflect, really, the complexity or the difficulty of the types of procedures that we do.
You can end up doing a five-hour, very difficult, technically complicated peripheral nerve procedure and get paid $1,200 or less. That includes all the time you spend working up the patient, the time that you operate on them, and that also is supposed to cover a 90-day post-op period. It just got really, really difficult to run a practice on that kind of reimbursement. So, I was forced to make the jump to a cash-only practice for that reason.
