OBJECTIVES: Emphasis is being placed on putting the patient at the center of healthcare decisions and public reporting of quality outcomes while insurance reimbursement for patient-centered solutions is not keeping pace resulting in financial burden to patients.

METHODS: This case study, involves an analysis of claims data for the use of CWI or LIA. Medicare does provide reimbursement for this clinical service but only if specific requirements are met. What are these requirements and when are they met? The denial remark codes tell a story of the rationale for denial. If billed on a separate claim or provided by the Anesthesiologist versus the surgeon reimbursement methodologies differ.

RESULTS: Prolonged use of opioids after surgery has been named the “most common surgical complication”. Reportedly as many as 7% of patients continued to fill prescriptions for opioids greater than 3 months after surgery. The number of deaths from opioid overdose also continues to rise. In 2020 alone over 16,000 patients died from drug overdose involving prescription opioids. Continuous Wound Infiltration(“CWI”) and Local Infiltration Anesthesia (“LIA”) offer an alternative to opioid pain control. A general reduction in pain intensity and in opioid consumption is reported with LIA and CWI postoperatively. This is a clinical solution that not only lessens the need for opioids, it also decreases length of stay in the hospital setting and the need for IV pain control in the hospital setting. So, where does the problem lie? Lack of insurance reimbursement for the treatment resulting in patient financial responsibility when CWI or LIA is used following a surgical procedure.

CONCLUSIONS: Patient satisfaction is driven not only by quality of care but patient cost. A study of the American Medical Association shows that prior authorization and insurance reimbursement battles are the second leading cause of physician dissatisfaction and burnout.