Insurance Changes in 2021

By: Dr. Thomas M. Basch

Dear Patients:

As we enter 2021, I know that quite a few of you are concerned as to the possible changes in pain management. We share your concerns, and try to remain proactive so as to provide you with the best care we can. I am still awaiting the details on proposed changes, and indeed, am still awaiting formal announcements by Medicare and the other insurers on exactly what all of the changes will be.

I have information on a few changes. Don’t hold me to the details, though, because even when changes are actually implemented, we can expect alterations/additions/subtractions during the first quarter. At any rate, here we go:

  1. The pre-approval process for injections and other procedures is now more extensive. As doctors, we have additional questions we must answer about previous treatment effectiveness and future treatment plans. Most importantly, we must be able to document the amount and the duration of the pain relief each and every injection provides before further treatment authorization is given. For some of you, this will require a follow up appointment after every injection to assess the outcome and document it in the chart before any more authorization is given. We may or may not be able to do this by a phone call. We shall see.
  2. Fewer and fewer insurances will be allowing same day authorizations for treatment. In other words, if you arrive for your scheduled appointment, and you and I determine that the procedure we had been planning upon no longer makes as much sense as an alternative, it will take a few days or weeks to get permission to do that alternative.
  3. Some insurances are further cutting back on coverage for injections. For instance, if we treat both your left and your right L5 nerve root, the insurance will be considering that to be TWO injections. If the insurance has a yearly limit on the number of injections it allows you to get, by getting treatment on both sides, you will be using up TWO of your 12 month injection allotment.
  4. If you are on blood thinners (Plavix, Xaralto, Coumadin, Eliquis, etc.) we are going to have to work through some more hoops in order to inject you. I’ve heard that a few insurers will require that we have a specific plan from your primary doctor or cardiologist on the chart regarding how the thinners are to be managed before we can get authorization to inject you. Obviously, if we don’t have that information on our chart for your appointment, we wouldn’t be able to treat you that day.
  5. Some insurances are further restricting specific narcotic/opioid painkillers, by either refusing to cover certain ones at all, or by requiring you to use safety enhanced formulations of the medication.
  6. A few carriers, from what I’ve heard, are going to require participation in physical therapy between injections. I don’t know what “participation,” means yet, but I’ll tell you what I learn when I learn it.
  7. We are going to have to update MRI and CT scan studies more frequently for some of you. In the past, if an injection had been helping you well time after time, we could continue to perform it every few months unless/until your symptoms changed. Now, it sounds like we’ll need to periodically order and obtain studies to confirm that the same anatomic issue we’ve been treating is indeed still your problem.

I don’t have information as to what changes you’ll face in terms of your costs/copays for various treatments. Unfortunately, the trend always seems to be upwards.

We will keep you posted as 2021 unfolds, and we will do our best to adapt and adjust.

One more time, I’ll emphasize that It is critically important that we be able to document amount of relief and duration of relief each time you receive an injection. Otherwise, we may not be able to get authorization for further injection treatment.

* All information subject to change. Images may contain models. Individual results are not guaranteed and may vary.