FAQs for Spine Centers of Excellence
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Shared decision-making
Referrals
Service performance standards
What is the Priority Health Spine Centers of Excellence program?
Spine Centers of Excellence are physiatrist-led clinics whose focus is the non-operative, comprehensive management of spine problems. For patients whose condition does not require urgent or emergent surgical evaluation, Priority Health requires evaluation in a Spine COE before surgical evaluation.
Why is Priority Health implementing a Spine Centers of Excellence program?
Priority Health is committed to providing access to high-quality, affordable health care. There is a growing body of evidence that an increasing number of patients with neck and back pain can be treated non-operatively. Evidence also shows multi-disciplinary spine clinics can reduce back surgery rates. This is consistent with Priority Health data that shows an inverse relationship between physiatry utilization and spine surgery rates.
What are the goals of a Spine Center of Excellence?
This initiative has three objectives:
- To ensure all patients with neck and back pain have timely access to a comprehensive medical evaluation
- To provide resources to ensure all patients are fully informed of all treatment options
- To coordinate both surgical and non-surgical care and management
How does a practice/provider become a Spine Center of Excellence?
The center must meet specific criteria in the following areas:
- Financial independence
- Core staffing that includes a physiatrist, therapist and care coordinator
- Aligned medical and surgical consultants
- Diagnostic services
- Use of evidence-based guidelines
- Use of shared decision-making tools for common conditions
- Collection and reporting of clinical outcomes
What is the application process?
To be a Spine Center of Excellence, a physiatrist must complete the application and meet all of the requirements specified in the Spine Centers of Excellence policy. Priority Health staff will work with applicants to help them understand and meet each requirement.
How are Spine Centers of Excellence reimbursed?
See the information in the Billing & Payment section of this Provider Manual on Spine Centers of Excellence.
Is prior authorization necessary if the patient has Priority Health as secondary insurance?
No, prior authorization is not required when Priority Health is the secondary insurer.
What products does this apply to?
This applies to all Priority Health products.
Shared decision-making
What is shared decision-making?
Shared decision-making is the process of information sharing between a patient and physician that includes diagnosis, possible treatment choices, the benefits and risks of each choice and consideration of the patient's values and goals for treatment. Part of shared decision-making may include information gathering by the patient, such as watching the DVDs Priority Health has provided to the Centers of Excellence.
What conditions/diagnoses are covered in the patient DVDs?
There are 4 DVDs, which cover the following:
- Herniated disc
- Spinal stenosis
- Acute low back pain
- Chronic low back pain
Is the use of shared decision-making tools required?
No. However, since the typical patient's recall of information is poor, and family members benefit from hearing the same information, we encourage you to use these DVDs. They especially benefit patients who may need to hear the information you have already presented another time. We strongly encourage the use of these tools for patients who want to see a surgeon.
Can these tools be used for any of my patients?
Yes, the tools are available for all patients, not just Priority Health members.
What are my options if I do not have space in my office for a separate room for patients to view these DVDs?
The DVDs can be sent home with each patient along with a return mailer/envelope. The patient can use the mailer to return the DVD or can return the DVD at the next visit. Priority Health has developed tracking sheets to help your office track the whereabouts of the DVDs. While the DVDs are available at no cost to your practice, we respectfully request that each Center of Excellence make every effort possible to retrieve each DVD.
Who is responsible for tracking who has the DVDs?
While the DVDs are available at no cost to your practice, we respectfully request that each Center of Excellence make every effort to retrieve each DVD.
How many copies will our Center receive?
The number you receive depends on how you distribute them to patients. If patients will view them only in your office, 2 of each of the 4 is typically adequate. If you intend to send them home with a return mailer, then for a practice of 5 physicians, 10 each of the herniated disc, spinal stenosis and chronic low spine DVDs, and 5 of the acute low back pain DVD.
Referrals
What are the primary referral requirements in this program?
The referral requirements are as follows:
- Prior authorization is required for all referrals to orthopedic or neurosurgeons for back or neck pain and other spine-related complaints as outlined in the medical policy.
- Evaluation by a Priority Health Spine Center of Excellence is required prior to referral to an orthopedic or neurosurgeon for back or neck care/evaluation unless there is an acute indication for surgical evaluation (see #3).
- Surgical evaluation of back or neck problems does not require a Spine COE evaluation for the following (prior authorization still required):
- Evidence of tumor, infection or fracture.
- New onset of bowel incontinence, or bladder incontinence, or retention (cauda equina).
- Progressive upper or lower extremity weakness or myelopathy. Myelopathy is defined as cord compression with clinical bilateral "long tract signs" and potential for bowel and bladder control compromise. Rarely if ever would this be present with a mild weakness or unilateral foot drop. True acute myelopathies require urgent evaluation to rule out a surgical emergency.
- Follow-up to emergency care provided in the ER or inpatient setting.
- The referral requirement does not apply in the following circumstances:
- Non-spine-related care provided by neurosurgeons or orthopedic surgeons.
- Care provided in an inpatient or emergency department.
- Patients <18 years of age.
What is the process for a Priority Health member to be seen at a Spine Center of Excellence?
Any participating physician can refer someone to a Spine Center of Excellence. A referral does not require prior approval by Priority Health. However, all referrals for spine-related problems to a spine surgeon require prior authorization and plan approval.
Who can make referrals to a Spine Center of Excellence?
PCPs, ER physicians or urgent care centers and other specialists, including surgeons.
Can a Spine Center of Excellence refer a patient directly to a spine surgeon?
Yes, but, as noted above, it requires prior plan approval. If, after the COE evaluation, surgical evaluation is indicated, Priority Health will approve the physiatrist's request for consultation.
What if a patient still wants to see a surgeon after evaluation in the Spine Center of Excellence?
The intent of the program is to have patients understand all the medical and surgical options available to them. If the patient still desires to see a surgeon, the center or the primary care physician can refer to a surgeon. Prior approval by the plan is required.
Can a Spine Center of Excellence refer directly to therapists, pain specialists, neurologists or other specialists?
Yes; however, Priority Health strongly encourages each Center of Excellence to work with the primary care physician when doing referrals.
Can a referral to a surgeon be made by an ER or urgent care doctor?
Yes, but prior authorization by Priority Health is required. There are no referral requirements to specialists, with the exception of spine surgeons for selected diagnoses.
How have primary care providers been educated?
Priority Health has used several methods of educating primary care providers regarding both the availability of the Spine Centers of Excellence and the requirement for prior authorization of surgical consultation. Methods include direct mailings, PHO leadership and office manager education, and Priority Health physician account executive office visits.
Whom do I call if I have more questions?
Please contact your Priority Health physician account executive (PAE) directly or through the Provider Help Line.
Service performance standards
What are the service performance standards for access and reporting?
Timely access to each Spine COE is critical to patient and provider satisfaction with the overall program. All referrals must be evaluated within two working days, either in person or telephonically. For telephonic triage, the Spine COE staff can decide when to see the patient, but all acute cases should be seen within 10 business days. Chronic patients should be seen no later than four weeks.
Reports to the referring physician must be sent within 4 days of each encounter.
How will Priority Health monitor access and reporting timeliness?
Priority Health will not do a formal audit of either unless patient or primary care satisfaction surveys demonstrate a problem.
Also see:
FAQs for PCPs
FAQs for Surgeons
