RUNNING YOUR PAIN

MANAGEMENT AT MAXIMUM

EFFICIENCY

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Becker's ASC 23rd Annual Meeting The Business and Operations of ASCs

October 27-29, 2016Swissotel, Chicago, IL

Copyright © 2016 Mowles Medical Practice Management, LLC. All rights reserved

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This Business of Pain

Patient’s need to resolve their pain disorder… think about the patient's experience in your ASC from scheduling to discharge.

You have 1 time to get this right!

Professional Beyond Appearance

• You must offer prompt, courteous, compassionate and professional services.

AND..

• You should be offering the most advanced, market driven, proven techniques at a fair fee.

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Cross Train Staff

Train Radiology and/or surgical technicians to:

Process sterile supplies

Take vital signs

Place patients in pre op rooms for RN

Assist in PACU to discharge patients.

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Booking

An ASC that is accustomed to doing only 2

cases per hour may have trouble keeping up

with a specialty such as Pain Management.

Don’t give up, make adjustments.

Above all else, STAY ON TIME. If you are

running behind, keep your patients and

their responsible party (driver) advised.

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Your Staff Is Key To Keeping Pain Cases

•If you train your staff to apply the same criteria as you

would yourself (by example and full explanations) then they

will be exercising your control on your behalf.

•Communications with staff and how they communicate

with your patients, insurance companies and referral

sources.

Operational And Business Functions

Efficiency Musts

• Quickly responding to telephone calls

• Limiting waiting time

• Effective and efficient scheduling - Modify hours of availability based on case volume

• Responding to satisfaction surveys and comments left in suggestion boxes, complaints and complications

• Paying careful attention to new patients and referrals

• Always staying focused on your customers

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The 3 A’s

• Availability—work out shared call systems, but be careful about “who you get in bed with.”

• Affability—remember you have many customers: patients, referral sources, hospital personnel, 3rd party payors.

• Ability—stay up to date.

SOME SAY,

“AVAILABILITY, AVAILABILITY, AVAILABILITY”

Unique Identity

OBJECTIVE

Clearly define in specific terms

IMAGE

• State the types of pain you are going

to treat and how

What specific specialty?

With what specific training?

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Unique Identity, Continued

• Do your pain providers refer patients for

ancillary/alternative services?

• Do your providers have an expertise in certain

procedures?

• Speak a language native of that community?

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Unique Identity, Continued

• Training, Continuing Education and Board

Certification

• Strengths in clinical operations

• Patient loyalty - Satisfied patients will spread the

word

• Referring physician loyalty

• Effective use of staff time and strengths

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Referrals

• Serve as a resource to current and potential referring physicians for pain management advice and/or clinical assistance

• Discuss new techniques, recent successes and always serve as team players

• Keep referring physicians informed and part of the treatment plan

• Thank them for the opportunity of being involved in their patients overall care.

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Bring On New Physicians

• Carefully seek out the best providers and then ensure these physicians are a good fit for your ASC

• Offer ownership/partnership

• There simply is not the same buy in on time and resources without

• Obtain mandatory peer references, use web based background checks as well as verification sources

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New Providers, Continued

• Do not be shy about looking over [the recruited] physicians work

• Watching for warning signs of poor care …

• Not returning calls or answering pages, frequent complaints and mishaps that could be avoided with precautions.

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Privileging

If your providers are not Fellowship trained/Board Certified, use a specific privileging form to ascertain their training and experience with not just pain management core privileges, but also with the more invasive, provocative procedures.

Set up a standard for what their education and experience and ongoing training must be.

The best marketing is

educating.

You get more 'bang for your

buck’ speaking to doctors than

patients, but some speaking to

patient groups can generate

lots of good will.

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Community Awareness

Awareness Suggestions

• Give presentations to local groups

• Volunteer to answer questions on radio or TV talk

show

• Build external creditability through promotional

activities and educational public relations

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Continually Measure Efficiency

Telephone calls

Waiting time

Responses to satisfaction surveys

Comments left in a suggestion box

Complaints

Complications

New patients and referrals

Stay focused on WHO are the customers

Supplies

$ PLEASE negotiate on your epidural and nerve block

trays – GPO’s or purchasing organizations can help

save significant $

Or,

$ Consider picking items off the shelf vs. using packs,

the amount of time it takes to pull the 10 things you need for

a pain case takes seconds.

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Payor Relations

• Communicate algorithms', protocols, and then costs and reimbursement

• QAPI studies

• Benchmarking mandatory - Outcomes, Procedures, Patient/Physician/Staff Satisfaction and Practice Management

• Utilize peer review through national clinical outcomes studies.

• Use demand for types of services in your favor

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TreatmentOptions andOutcomes

Payor Relations, Continued

• Review all contracts closely before agreeing to any terms. PLEASE re-visit upon termination date!

• Case Rates

• Multiple Procedures

• Carve outs

• Always inquire as to their reimbursement re changes in CPT codes and descriptions

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Payor Relations, Continued

• Ensure all payor contracts are loaded into your billing and collection software

• Drop the payor if they have unilateral changes in product participation

• Discuss all costs with the payor during contract negotiations

• Train ALL staff in patient collections

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Payor Relations, Continued

CLEAR financial policies on your charges for cancellations or no-shows (PREVENTION is #1)

Collect all co pays and co insurance at time of service, offer payment plans and “Care Credit”.

Verify Eligibility

Pre Certification/Pre Authorization

Valid Referral?

Medicare “non grouped” (off-list) procedures?....Discography,

Consider self pay for PRP, stem cell, lidocaine infusion, only ASC covered procedures only!

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File Clean Claims

Know the nuances of pain billing

Bundling issues?

Covered diagnosis? Medical Necessity?

Know what modifiers apply to the ASC

Be aware how each payer wants bilateral and multiple procedures reported.

Are there procedure limits?

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Procedure Type Considerations

•Staffing and equipment or supplies you will need

•Realistic reimbursement expectations

Revenue has to be viewed in context of risk, hours input, etc.

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Procedure Type Considerations

Run a utilization report

Determine highest paying services

Determine lowest paying services

Capitalize on this data by:

Eliminating services that are not within the facility profile

Reducing volume of some procedures that are not reimbursed at

a level that covers your costs

Increasing volume without increasing staff

Promoting procedures with highest payment and best treatment

outcomes

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Exodus of Pain Management Procedures

to Offices

ASC’s must understand the site of service differential decline.

Be well versed on the service overhead.

Know your own State regulations affecting

office surgery.

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Reimbursement by Venue – MCR NAA

CPT Short Descript ion Pro Fee

Non-Facility

Pro Fee

Facilit y ASC Facilit y Fee

27096/

G0260 Inject sacroiliac joint $165.52 $87 $327.22

62311 Inject spine l/s (cd) $228.94 $93.15 $327.22

64483 Inj f oramen epidural l/s $225.36 $116.80 $327.22

64493 Facet Joint l/s 1 level $177.71 $94.94 $459.71

64620 RF l/s 1 level $211.03 $178.42 $459.71

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Cost Reality

Item Description Cost/CaseEpidural Tray $8 - $15

Contrast Dye $15 - $25

Equipment $60 - $100

Staffing $30 - $50

TOTAL $113 - $190

Payment for Space? Utilities? Physician Payment?

What components above are covered separately?

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Pain Management Procedures in

Offices

Source-AAAHC

28 State Health Departments have regulations and jurisdiction. Typically driven by:

Levels of anesthesia used and/or

Complexity of procedure performed

$Licensed

$Registered

$Accredited

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Regulated States for Office Surgery• Alabama

• Arizona

• California

• Colorado

• Connecticut

• Delaware

• District of Columbia

• Florida

• Georgia

• Illinois

• Indiana

• Kansas

• Kentucky

• Louisiana

• Maryland

• Massachusetts

• Mississippi

• Montana

• Nebraska

• Nevada

• New Hampshire

• New Jersey

• New Mexico

• New York

• North Carolina

• Ohio

• Oklahoma

• Oregon

• Pennsylvania

• Rhode Island

• South Carolina

• Tennessee

• Texas

• Utah

• Virginia

• Washington

• Wyoming

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Additional Office Regulations

Pending: FGI Guidelines Committee have suggested physical environment standards for Accredited Office Surgery practices

Radiology Regulations vary from State to State and/or Individual Payor

Certified Radiology Technician vs. Other?

Mandatory training program (Example: GA)

State Certification program (Example: CA)

Competency statement (Example: MA)

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Pain Psychology in Practices

• Extremely important – if this is not part of your

practice, then have a close working relationship with

psychology colleagues

• Develop pain psychology protocols that allow you to

refer your patient for pain treatment rather than for the

treatment of psychopathology.

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Multidisciplinary Pain Care

• Look big and comprehensive while keeping

overhead down (CRUCIAL)

• May involve outside providers (PT, OT,

Rehab, Aqua Therapy, Acupuncture,

Massage, Chiropractic, Yoga)

• Must appear as a package

• Many different possible arrangements

• Set aside weekly time to meet with the

team.

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Pain Practice Expansion

• Consider expanding your practice into

cancer pain and palliative medicine

• Recognize that this may significantly

increase demands for availability.

• Very rewarding work

• Know your community resources:

• Detox programs

• Inpatient pain programs—don’t be afraid

to refer the very difficult patient

• A variety of excellent specialists and

primary care doctors

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Relevant Records

• Obtain relevant records

from referral sources

and PMDs

• Can become crucial if

you will prescribe

controlled drugs

• Can help determine the

appropriateness for

procedures

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Medication Protocols

• Follow up with medication patients on regular intervals

• Physician extenders are a GREAT help with this

• Track all prescriptions: flowsheets or duplicates of scripts.

• Check labs periodically on patients that are on continuous medications.

• Regarding controlled medications—run a tight ship. Refill only when due.

• Have protocols in place for consent and education regarding pain medications and pain procedures.

• DETAILED risk/benefit

Prescribing Controlled

Substances

• Must provide a Code of Conduct as a Providers

Guide to Pain Management Prescribing Compliance

• Include Universal Controlled Substance Policies for

Providers

• Medical Staff Rules And Regulation for prescribing

• Include National and Carrier Specific Proper Coding

and Documentation to Establish Medical Necessity

for Procedures38

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Final Thoughts

Expand the hours

Expand or even narrow the scope

of services

Enhance the efficiency

Enhance the profitability by Venue

Choice

Case Cost Management

Or:

Do not change a thing…..depends on your

own tolerance for risk

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Helpful Links and Resources

o CMS Transmittals –

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2016-Transmittals.html

o American Society of Interventional Pain Physicians-

http://www.asipp.org/index.html

o Index to State Departments of Health

http://www.cdc.gov/mmwr/international/relres.html

o Medicare State Operations Manual (Conditions for Coverage)

http://www.cms.gov/manuals/downloads/som107ap_l_ambulatory.pdf (*See appendix L and appendix I)

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Edgewater, Maryland 21037

Phone (410) 956-1907

Fax (443) 782-2386

E-mail: amy@mowles.com

www.mowles.com