The decision to treat a fracture with or without surgery is based on a number of different factors. The specific bone that is fractured, the alignment of the fractured pieces, the involvement of a nearby joint, the age of the patient, and the activity level expected after recovery all influence this decision. The time required to return to activiteis, both with and without surgery, may influence this decision as well. In general, if the result of nonsurgical treatment is equivalent to surgical treatment, nonsurgical treatment is preferred. These decisions are best made by the patient (or parents) and the doctor. Insurance company policy should have no impact on this decision.
The insurance company does, however, influence how this type of care is covered. Insurance companies like to anticipate their costs and try to distribute risk over a broad population to make their expenses more predictable. This is true of insurance in general but particularly relevant to this specific situation. Not every fracture heals the same way. Some fractures require closer monitoring than others. Some fractures heal quicker than other. Some require 2 or 3 office visits; others require 6 or 10. In an effort to better control their costs, insurance companies have developed a concept referred to as a global payment. Rather than pay for each individual office visit required to monitor a fracture healing over 2 to 3 months, the insurance company prefers to reimburse the physician the same amount for every fracture of a particular bone . This means that an insurance company will pay one set fee for a particular fracture. This is a fee set by the insurance company, and agreed to by contracted physicians, for the care of this fracture for 90 days. It does not matter if a patient comes in once a week, once a month, or simply once – the payment for this fracture is the same – a single payment of one lump sum to the physician. This is the global fee for this care. The global fee covers the physician’s expertise and care for this particular problem. The global fee does not cover xrays that may be necessary to assess the fracture during this time period. It also does not cover any braces, splints, or casts required during the care (with the exception of the first cast applied on the first day of treatment). This fee does not cover any therapy that may be required after the fracture heals in order to restore proper function of the affected area. This fee simply covers the professional services of the physician but it includes the entirity of the doctor’s services for 90 days.
The other important feature of this type of billing and reimbursement arrangement is the way this care is categorized or coded. Medical services are all coded with 5 digit codes to allow clear communication between physicians and insurance companies about what type of care was provided to patients. There are major categories within these codes that designate the type of service or care that was provided. Some examples of these categories are office based evaluations, office based procedures, hospital based care, radiology procedures (xrays, CAT scans, MRI), and surgical care. The codes used for nonsurgical treatment of a fracture are in the same category as surgical care of fractures. This does not mean that the doctor is giving the insurance company the wrong code or suggesting that surgery was performed when it was not, this is just the way the codes are grouped. Closed treatment of a wrist fracture (meaning nonsurgical treatment – not open) is in the same group of codes as open treatment of a wrist fracture (meaning an incision and some sort of internal stabilization of the fracture). One is surgery while the other is not but they are both in the same group of codes. I do not know why codes are grouped like this. No one asked me how they should organize the codes. The significance of this is two fold.
#1 – The statement that insurance companies send to patients, detailing what type of care they have paid for to the treating physician, may indicate that a surgical procedure was paid for when nonsurgical treatment of a fracture is provided in a physician’s office. This is not a mistake and it is not fraud. This is because the nonsurgical fracture care codes are in the surgery section of medical codes.
#2 – The designation of nonsurgical care as surgery may mean that your insurance company categorizes this care under the major medical portion of your insurance policy, not the office based care portion of your policy. This may have implications on your deductible or copay for this type of care. This is a decision your insurance company makes, not your physician. Most insurance companies do not allow the physician to charge for office visits, instead of the global fee, for fracture care. Your doctor is required to follow the requirements of the insurance company if he has agreed to a contract with them. Many patients get frustrated by this policy because they may have a large deductible or a higher copay for major medical care and they end up paying for more of this out of their own pocket. Realize that these policy decisions are make by the insurance company, not your physician.