How to Improve Profitability at Pain Management Practices
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Compared to other medical specialties, pain management is a specialty in flux wherein the practices face certain unique challenges related to increased state and federal regulations. These new regulations have resulted in several changes in coding and payer reimbursement policies thereby increasing the need or importance of efficient pain management medical billing and coding services. The methodology and efficiency of reimbursement for pain management procedures has undergone a drastic change over the past few years. Gone are the days when you could simply bill and get paid within 30 days. The industry in itself has evolved to incorporate more rigid policies and guidelines that regulate the use of pain medications. In addition, prominent changes related to payer policies on notifications, coverage and reimbursement has been launched. Since ICD-10 went into effect in October 2015, it has become increasingly difficult for physicians to meet the demands of payers and federal regulators for pain management procedures. There are many concerns involved. •
Obtain prior-authorizations – Before providing the procedures, payers require physicians to obtain pre-approvals. The procedures will be approved only if providers can show adequate evidence that these services are out of medical necessity and that other conservative therapies have failed. Comprehensive medical documentation has to be submitted to prove medical necessity.
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Limitations on the number of procedures - Payers have specific guidelines and limitations on how many times physicians can perform these procedures. Practices may have to undergo post-service, pre-payment coding reviews. When physicians follow their routine interventional pain procedures that have been effective in the past, claims are now often being denied by payers. To cut down total costs, payers are limiting the type of procedures to be performed in surgery centers and shifting certain procedures to physicians’ offices.
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Post-service prepayment coding reviews - Practices may have to undergo postservice prepayment coding reviews. 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, it is important to prove that the said procedures are warranted and the evidence is accurately documented in the medical record.
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Complete history of patients – Physicians need to show a complete picture, including complete medical history of the patients. Physicians face the unique
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challenge
of
following
more
detailed
requirements
in
the
local
coverage
determinations (LCDs) by including several questions concerning – ▪
Type of diagnosis
▪
Number of times the procedure has been performed
▪
Whether the patient has undergone conservative or alternative treatment methods
▪ •
Reduction in pain experienced by the patient
Controls on prescription of drugs – Physicians face more controls on prescribing drugs or combinations of complex drugs. Physicians need to prove whether the treatment modality administered was actually required and is a proven pain management procedure suitable for that particular patient’s body.
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Non–reimbursement for “experimental” procedures - Payers have started denying procedures that they consider “experimental” and not proven effective even though other insurance companies may have been reimbursing for the same procedures for years. While the recommendations from the Centers for Disease Control and Prevention (CDC) and new guidelines from the American College of Physicians suggest the use of alternative non-pharmacologic treatments, payers do not reimburse for some of these alternative therapies.
•
Medication management – There are stringent policies regulating the use of pain medications that providers need to understand. With higher number of people depending
on
pain
medications,
many
physicians
are
under
scrutiny
for
overprescribing them without proper clinical management. All the above mentioned guidelines and regulations, payer policies, medication management and post-service prepayment coding reviews make reimbursement for pain management a challenging task. This line of specialty requires a thorough understanding regarding payer rules and new codes, managing the costs of procedures performed, and determining what steps are to be undertaken to better take care of patients. According to reports from the American Academy of Pain Medicine, pain affects more Americans than cancer, diabetes, and heart disease combined, with the number of potential patients reaching millions. Physician practices, if taking the correct steps can get successfully paid for these procedures and increase their revenue. Here are certain steps that can help: •
Know payer rules and new codes - Pain management physicians need to have thorough knowledge about payer rules and ensure accurate claim submission using
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the latest ICD-10 and CPT codes. CPT 2017 has introduced new pain management codes and also deleted several codes. There are also several CPT code revisions. •
Manage costs of pain procedures - Often, many pain management centers begin their treatment process with simple procedures such as epidurals and, as needed and within payer guidelines progress to more complex procedures such as radiofrequency ablation (RFA). These centers should be innovative in understanding and managing the costs of these therapies. They also need to be aware about the difference in costs such as performing a procedure in a clinic versus a surgery center. Knowing these costs will help to determine whether the reimbursements justify the costs.
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Accurate documentation - Half of the process is complete with having accurate documentation and well-educated coders. Expert coders should know anatomy, understand how the physician is performing a procedure, know whether the information in the operative note is correct and understand how to pull that information out of the operative note and assign the correct codes.
Physicians
should continually educate themselves about what constitutes a well-documented operative note to avoid payer approval issues. They also need to know how to fit new procedures into the electronic medical record, as there won’t be templates for every type of procedure performed. •
Negotiate contracts better – Pain physicians, once they are aware about the costs of the treatment modalities they provide, can negotiate with payers in a better manner. Negotiating a contract requires adequate knowledge about the financial analytics and a good understanding about the complexities involved in the pain management domain.
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Patient population – While catering to the Medicare and Medicaid populations, physicians must also focus on improving their business by having patients with commercial and workers’ comp insurance to stay competitive.
The conventional revenue cycle billing practices will not be sufficient in this complex scenario in 2017. Conducting a deep ground-level analysis for reimbursement of painmanagement is crucial. An ideal option for pain physicians is to partner with an experienced medical billing and coding company that has expert AAPC-certified medical coders on board. Expert assistance and direction can help ensure accurate documentation as these coders would know whether the operative note has the right information and also how to assign the correct codes based on the correct information.
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