The methodology and efficiency of reimbursement for pain management procedures have drastically changed over the past few years. Gone are the days when you could simply bill the procedure and get paid within 30 days.
The industry has evolved to incorporate more stringent policies that regulate the use of pain medications. We have also seen changes in payer policies on notifications, coverage, and reimbursement.
Since ICD-10 went into effect in October 2015, centers have found it increasingly difficult to meet the demands of payers and federal regulators for pain management procedures.
Payers are now asking physicians to obtain pre-approvals (provide notifications) prior to providing the procedures. The procedures are only approved if providers can show adequate evidence that services are required and other conservative therapies have failed. Payers have specific guidelines and limitations regarding how many times the physicians can perform the procedures. Providers are also facing post-service, prepayment coding reviews. When physicians follow their routine interventional pain procedures that have been effective in the past, the reimbursements are now often getting denied by the payers.
Payers are also limiting what services can be performed in surgery centers and are shifting certain procedures to the physicians’ offices, thereby reducing their costs.
Physicians who are accustomed to being paid in 30 days are seeing payments held up as long as 180 days because the claims are often flagged for review. To obtain approval, you must prove that the procedures are warranted and that the evidence is documented in the medical record. You must show a complete picture, including a full history of the patients. Physicians face the challenge of following more detailed requirements in the local coverage determinations (LCDs), including questions concerning what is the diagnosis, how many times the procedure has been performed, whether more conservative and alternative methods have been tried, and how much the patient’s pain has been reduced. Physicians face more controls on prescribing combinations of drugs and complex drugs. The big question? Whether the treatment was needed and is a proven pain management procedure that works on a particular patient’s body.
Payers have also started denying procedures because they consider certain treatments to be “experimental” and not proven effective even though other insurance companies may have been reimbursing for the same procedures for years.
We have also read recommendations from the CDC, and new guidelines from the American College of Physicians suggest the addition of alternative methods of pain treatment that are non-pharmacologic in nature. How do your providers and your center make money when payers don’t reimburse for some of these alternative therapies?
Payers have not been prepared for the deluge of pain management claims or the amount of time required to review them to ensure that they meet their guidelines. They are contracting with beneficiary advisory companies to handle approvals.
Medication management is another critical concern that providers need to understand. With a growing epidemic in which people are becoming highly dependent on their pain medication, many physicians are being targeted for overprescribing pain medication without any clinical measures for managing the prescribed pain medication.
With these many guidelines and regulations, payer policies, and prepayment/post-service coding reviews, reimbursement for pain management isn’t what it used to be. Therefore, growing this business line is more difficult and takes an increasing amount of work. You must understand the payer guidelines, determine what needs to be done to take care of patients, and stay within the guidelines. The stakes are high because pain procedures often provide significant revenue.
Pain affects more Americans than cancer, diabetes, and heart disease combined, with the number of potential patients reaching into the millions, according to the American Academy of Pain Medicine. You can be paid successfully for these procedures, and even increase your business, if you take the right steps. Your patient population is key. While you still want to cater to the Medicare and Medicaid populations, you must grow your business and have patients with commercial and workers’ comp insurance to stay competitive.
Many pain management centers are starting their treatments with simple procedures, such as epidurals and, as needed and within payer guidelines, progressing to more complex procedures such as radiofrequency ablation (RFA). Centers should be innovative in understanding and be managing the costs of these therapies. It is also critical to manage your programs from a clinical perspective. You must understand what is happening at the clinical level so you can know, for example, what the costs are to perform a procedure in a clinic versus a surgery center.
Knowing these costs is critical to contract negotiations. Negotiating a contract is much more than just accepting a contract and signing on the dotted line. To take advantage of the opportunities in pain management, it is important to be involved with your contracting division and your revenue cycle company. It is highly advisable to approach contract negotiations as a science with financial analytics and a thorough understanding of the business, the patient population, and the complexities of the workflows that are involved – before the patient even gets on the table. You should evaluate the costs of your top procedures and determine whether the reimbursements justify the costs. Understanding the overall marketplace is also critical. With strong contract management and robust revenue cycle processes, you can obtain the reimbursements that make economic sense to run your business. Work with your business development team to look for strategic partnerships that will benefit from having you as their local pain physician. Such payers are looking for the right providers that their members can visit. Having strong referral sources in your local market is helpful to bring in new patients.
Using technology to move beyond the old-fashioned treatments of simple injections can help benefit patients and centers. Newer implants, for example, are much smaller, focused, and more effective. Exploring and adding services can open new revenue streams. Other new treatments include neuro-stimulation, pain pumps, interspinous spacer procedures, as well as new technology for the dorsal root ganglion stimulators. Centers also are extending their services to areas such as physical therapy and behavioral health to complement the core business. Several have also figured out ways to provide durable medical equipment (DME) to help patients manage their pain.
You also must focus on coding to thrive with pain management. Half of the battle is having accurate documentation and well-educated coders. You need expert coders who know anatomy, understand how the doctor is performing the procedure, know whether the information in the operative note is correct, know the payers’ expectations, and understand how to pull that information out of the operative note and assign the correct codes.
They must have accurate and complete documentation in all areas of the operative note that show what occurred in the session with the patient. If the information is lacking in the record, such as an issue with laterality or which nerves were treated, coders must clarify this information, and physicians must include it in an addendum to the original operative note.
Documentation can be an issue. Physicians often work with templates, but there isn’t a template for every type of procedure performed. A physician might try to fit a new procedure into an existing template, but doing so is like trying to fit a round screw into a square hole. It just doesn’t work. Continually educating physicians and giving them feedback by showing them examples of well-documented operative notes can help avoid problems with payer approval.
You need a financial division that has done the analysis and can tell you what the costs are for pain management procedures across the country. You need a deep dive, with ground-level analysis, that shows what is working and not working with your reimbursement for pain management. You need data to negotiate stronger contracts, and you need advice on your business strategy. With the right assistance and direction, your pain management program will not only survive in 2017, but it will thrive.
Source: Becker’s ASC Review
This post was first published May 2, 2017 and was updated July 29, 2020.