Improving the Efficiency of Pediatric Spinal Fusion Precertification

Precertification is a method implemented by insurance to reduce unnecessary spending. Unintended consequences include time and resources used to obtain precertification or appealing a denial. There was a perceived increase in denials and peer-to-peer interactions in our pediatric spine center during 2022. This quality improvement project was developed to reduce the burden of time and resources designated to these appeals.

A Pareto analysis of the causes leading to spinal fusion denials was performed. The team brainstormed and developed a key driver diagram and proposed interventions. Then standard plan-do-study-act cycles were observed to evaluate the effects of the interventions. The interventions implemented included a standardized preoperative template. Also, we altered the timing of the preoperative visit from 2 weeks prior to the procedure to at least 4 weeks prior. The initiation of the first intervention began in March 2023 followed by the preoperative visit change in May 2023. Data were collected through June of 2024.

The Pareto analysis showed "supporting documentation" was the top reason for spinal fusion denials followed by "not medically necessary." The first change idea initiated in March 2023 included the development of spinal fusion preoperative template. The second change idea, timing of preoperative visit from 2 weeks prior to at least 4 weeks prior, was implemented in May 2023. The median monthly denial rate fell from median 15.4% prior to May 2023 to 2.9% afterward.

Using quality improvement methods, two change ideas, a standardized preoperative template and having the preoperative visit at least 4 weeks prior to the procedure, led to significant decreases in the number of denials and peer-to-peer interactions seen during the precertification process. By targeting the top reasons for spinal fusion denials, we reduced denials for spinal fusion thus reducing the burden of peer-to-peer calls for surgeons. Methods such as this that improve efficiency and decrease administrative obligations may help larger efforts to avoid physician burnout.

(1)A Pareto analysis found that "supporting documentation" and "not medically necessary" were the top cited reasons for precertification denials for pediatric spine deformity correction.(2)A preoperative template including specific verbiage and elements that insurance companies require, such as curve magnitude, smoking history, fusion levels, and inadequacy of brace treatment, helped reduce precertification denial rates.(3)The preoperative visit was moved from 2 weeks prior to the procedure to at least 4 weeks prior to give adequate time to collect necessary information for precertification.(4)Following the implementation of these two change ideas, the median monthly denial rate fell from a median 15.4% prior to May 2023 to 2.9% afterward.(5)The use of quality improvement was an effective way to decrease the monthly denial rate and ultimately decrease the administrative burden of peer-to-peers on physician and nurses.

Level VI.