Medicare to cut office pain reimbursement by 20% or more this year

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Ligament

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Just heard some crappy news that medicare is planning to cut office based pain reimbursement by 20-70% this year, and increase hospital reimbursement for the same procedures! Please tell me this is false!
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Any links available to read about this?
 
"To eliminate incentives to perform services in an ASC that could be safely performed in a physician office, payment for office-based surgical procedures would be capped at the lesser of the non-facility practice expense payment under Medicare’s Physician Fee Schedule or the ASC payment rate. "

from a link with more specific info from CMS

http://www.surgicenteronline.com/hotnews/68h814294397076.html

not sure how to interpret this
 
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The practice expense is only one component of the RVU...the other components being the work component and the malpractice component..ordinarily the practice expence is about ?20-40% of the total RVU based on the procedure....

The proposed reduction will be in the practice expense.

Anyone know whether CMS is primarily using overhead expense data for 2007 from anesthesiologists (low overhead-hospital based) or from interventional pain physicians/physiatrists (higher overhead).
 
drrinoo said:
The practice expense is only one component of the RVU...the other components being the work component and the malpractice component..ordinarily the practice expence is about ?20-40% of the total RVU based on the procedure....

The proposed reduction will be in the practice expense.

Anyone know whether CMS is primarily using overhead expense data for 2007 from anesthesiologists (low overhead-hospital based) or from interventional pain physicians/physiatrists (higher overhead).
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That's the problem. Despite aggressive campaigning by ASIPP pain docs are not using the 09 specialty code. I think you need to reach a certain threshold in terms of numbers for CMS to do a separate practice cost analysis and we haven't reached it. The danger, then, is that they will use the anesthesiology practice cost for the calculation, which is far less than an office-based pain specialist.

As for the quote above about office and ASC fees, what they are saying is that if you do a procedure in the ASC that could be done in the office, the reimbursement is capped at office rates. They are trying to drive procedures into the office. They did this with oncology: they gave them financial incentives to do chemo in the office. After everyone went out on that limb they sawed it off and cut chemo reimbursement in the office.

The pain docs get off their butts and register under the 09 code, and Congress has to wake up to the fact that they are looking at 80 million Medicare beneficiaries entering the system as the boomers age. It simply isn't realistic to expect to keep expenses down when volume increases like that.
 
gorback said:
As for the quote above about office and ASC fees, what they are saying is that if you do a procedure in the ASC that could be done in the office, the reimbursement is capped at office rates. They are trying to drive procedures into the office. They did this with oncology: they gave them financial incentives to do chemo in the office. After everyone went out on that limb they sawed it off and cut chemo reimbursement in the office.
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Don't want to sound like a conspiracy theorist,

but are you saying this was a 2 part plan? Lure docs into performing in-office chemo (in this case procedures) and then cut the reimbursement?
 
Disciple said:
Don't want to sound like a conspiracy theorist,

but are you saying this was a 2 part plan? Lure docs into performing in-office chemo (in this case procedures) and then cut the reimbursement?
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Never attribute to malice that which can be explained by plain stupidity. We'll never know if that was the game plan with oncology all along, or if it evolved over time as CMS keeps searching for ways to keep expenses down.

However, it's going to be the same progression:

1. They notice that they can get the same service done cheaper in the office.

2. They give an incentive to do it in the office that is good for the person making the decisions on where the service will be rendered (the doctor) but still cheaper than a facility.

3. Once everyone is providing their services in the office they will cut the fee for office-based services.

They win at each step along the way. When you shift cases into the office they save money, and when they chop you off at the knees later they save money.
 
so it sounds like the door to go back to ASC's is closed, or is it? Im sure the hospital fees havent changed much since they have such good lobbyists....the hypocrisy....just like Stark. I cant own my own MRI center, but the attorney can, and he is allowed to self-refer his own PIP cases. Then i get the patient after he already charged and was paid $1500 for an MRI. And if i send the patient somewhere else for an MRI, even if it is alot closer to their home, i lose any more cases from that attorney.

T
 
You can own your own MRI but you can't refer Medicare to it unless it's under your roof. Other insurance is fine. However, they are gunning for all of the freestanding imaging centers anyway. Once again, I would suspect that the hospitals are behind this lobbying to eliminate competition.

The only way to make serious money in healthcare these days is to be the CEO of an insurance company or a hospital. Everything else has been picked over.

Watch out for the hospitals in the future. They are going to evolve into little healthcare nation-states with the docs and everything else under their umbrella.
 
would that be describing kaiser-perm in california?

T
 
Yes.

In general, if you want to know where the country is headed in socioeconomic terms watch California.
 
Funny,

Had a patient the other day recently S/P intrathecal pump implantation with new onset low back and searing leg pain. Admitted to Kaiser and put on a PCA for a few days and then discharged. Lumbar MRI read as normal.

Patient's pain persists for another week. Repeat MRI ordered and shows a large paracentral disc herniation. Patient admitted and undergoes open decompression within a few days.

I just found out that patients' signed up with Kaiser cannot sue Kaiser, even though they act as both the insurer and the provider.

That is scary if the rest of the country is headed in this direction.


Evil empire?:laugh:
 
I don't see how they can do that unless CA law allows it. Signing a contract doesn't waive those legal rights. Otherwise we'd have all of our patients sign a contract agreeing not to sue us. Track down that law and see if you can use it too!

In this case what could they sue for? How was the patient harmed? Delayed diagnosis resulting in pain for an extra week? Not much to build on there.

Moral of the story: always read your own films. Not all radiologists are created equal.
 
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gorback said:
I don't see how they can do that unless CA law allows it. Signing a contract doesn't waive those legal rights. Otherwise we'd have all of our patients sign a contract agreeing not to sue us. Track down that law and see if you can use it too!

In this case what could they sue for? How was the patient harmed? Delayed diagnosis resulting in pain for an extra week? Not much to build on there.
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I didn't mean a suit in this case in particular. I'm just starting to question the level of care one may expect when signed up with Kaiser.

Other things I've noticed, anytime a patient of mine gets hospitalized, the Kaiser physician will call me incessantly to arrange an immediate transfer. When you give them diagnostic work-up and treatment recommendations, they're hesitant to do anything that may inconvenience them in any way.
When a new patient transfers care to your practice, they make it impossible to get any medical records.

I guess that's what happens when all the physicians are on-the-clock/salaried.
 
When my patients complain about service issues I just tell them I didn't buy them the insurance policy and you get you get what you pay for.

Service, Quality, Price. Pick any two.

Since most people want low price and quality care, service usually gets sacrificed.
 
united... i strongly encourage everybody to break their contracts w/ united...


their contracted pain rates are a disaster - their service is a disaster (for example, they are having a "computer issue" for the last week and therefore remittances/claims can't be processes without any clear date for a fix), and once you sign a contract they will never raise your rates...

so now i am out of network with them, still seeing their patients as out-of-network, and making 4-5 times what they would have paid in network...

so after making tons of money off them i returned to the negotiating table to point out that maybe it would be beneficial for them to give me higher rates and make me in-network... and do you know what they said: "they don't increase rates in negotiations with solo practitioners" .... fine with me, they can continue paying me $400 for 99244 and $950 for 64483, 64484, 77003 (professional fees as i am currently hospital based).... what a bunch of idiots...

the good news is that I don't need united to survive - i feel bad for those docs who don't have a choice and must accept united to make a living.

one of my son's doctors has a sign in the waiting room: "I didn't choose your insurance company, you did... "
 
funny about United....here in Miami some of us pain docs are trying to do the same thing the ENT's did awhile back....everyone joined a "network" and United now pays them 100% of medicare. United pays me 80%...they offered another guy 65% and he told them to f/o. So he is now organizing this network. If anyone has experience doing this, feel free to PM me or chime in.

T
 
that's filthy.
According to ASIPP huge cuts are coming!!
 
100% of medicare?

hahahaha...

seriously, forget that, man.

When will docs tell medicare to piss off, and every other insurance company that doesn't offer @ least 125 of medicare%? I'm sorry, but this socialist stuff and manipulating our market price has got to stop.

Doctodd said:
funny about United....here in Miami some of us pain docs are trying to do the same thing the ENT's did awhile back....everyone joined a "network" and United now pays them 100% of medicare. United pays me 80%...they offered another guy 65% and he told them to f/o. So he is now organizing this network. If anyone has experience doing this, feel free to PM me or chime in.

T
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Tenesma said:
united... i strongly encourage everybody to break their contracts w/ united...


their contracted pain rates are a disaster - their service is a disaster (for example, they are having a "computer issue" for the last week and therefore remittances/claims can't be processes without any clear date for a fix), and once you sign a contract they will never raise your rates...

so now i am out of network with them, still seeing their patients as out-of-network, and making 4-5 times what they would have paid in network...

so after making tons of money off them i returned to the negotiating table to point out that maybe it would be beneficial for them to give me higher rates and make me in-network... and do you know what they said: "they don't increase rates in negotiations with solo practitioners" .... fine with me, they can continue paying me $400 for 99244 and $950 for 64483, 64484, 77003 (professional fees as i am currently hospital based).... what a bunch of idiots...

the good news is that I don't need united to survive - i feel bad for those docs who don't have a choice and must accept united to make a living.

one of my son's doctors has a sign in the waiting room: "I didn't choose your insurance company, you did... "
Click to expand...

do you collect the remaining ?40% from the patient or do you just write it off?
with most insurance contracts they stipulate that you can only collect the co-pay up front and then cannot bill the patient for the remaining amount, until the eob is processed.

however, I don't know if they mandate you make a good faith effort to collect the remaining amount....obviously 40% on a transforaminal or facet will be high for most patients.

if you don't make a good faith effort to collect, then there is potential risk of being reported to the state insurance board...but if you do make a good faith effort, then your a/r aging just creeps up...but at least your patients won't get mad at you about the amount owed

so, if you are out of network do you have a lax collection policy for your patients--outside of co-pays?
 
I tried to negotiated with United/Oxford, they said they would not negotiate for another year during the transitional merger period. I saw several EOBs denying multilevel MBB and TFESI levels, for whatever reason (computer issue). I dropped them for 1month and got back onto the network, because my patients were begging me and my revenue would have decrease somewhat. Furthermore, I believe your ARPP medicare payments from United are lost as well. IN anycase they bullied me as well (solo MD).

United/oxford patients know they are second class citizens, just don't know why that insurance company keeps on making huge profits...
 
i let the patient know that they will get three bills from me - and that they can create their own payment plan - wink, wink, wink... the patients totally understand and don't pay for the most part... but that is okay because i can demonstrate good-faith effort at collecting those bills. there is no rule that I have to go after them for the co-pay... in fact, as an out-of-network provider i NEVER signed a contract so technically they can't require me to do anything....

the problem you can run into is when united sends the checks directly to the patient - cause then you will never see a dime...
 
I took an insurance class in college. The point of an insurance company is to collect as many premiums as possible and payout as few claims as possible. That is all they exist to do. Medicare and Medicaid are insurance companies too.

I bet there was a clandestine plan to screw the onc guys in stages.

Its just like this pay for performance garbage. They say they will pay docs extra to meet certain criteria. Well after we all run around jumping through hoops for them to toss us a couple of peanuts they will yank the rug out from under us. Once we are all doing this pay for performance thing they will cease paying for it. Then it will turn into a big game of gotcha. Oh you didn't document the patient's temperature at the right time, so now we aren't going to pay for the whole visit.

Guys it is a conspiracy and doctors need to wake up.
 
so here we go again with this.....has anyone heard otherwise?
 
mille125 said:
wow...it is interesting that the biggest cuts are on E&M codes....supposedly medicare wanted to preserve/increase these...it appears that a revolution is coming....
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"i had to go to my doctor today, and he said he only takes cash" said one elderly women to another.
"Mine also, all the good doctors have dropped medicare"

i feel like we will hear this conversation a lot coming up in the near future.
 
Cards/Onc are looking at cuts up to 40%.

Rock on.
 
So, are these the annual cuts (due to the SGR) that we avert at the last minute every year?

What about the huge Medicare cuts coming through the Obama plan. The proposal by Senator Baucus is being voted on today right?
 
I believe the house plans addresses SGR but the senate finance bill left that out. Part of why the AMA supported "reform". We'll see what gets included in the final plan. My guess is the docs will left out as usual.
 
Disciple said:
So, are these the annual cuts (due to the SGR) that we avert at the last minute every year?

What about the huge Medicare cuts coming through the Obama plan. The proposal by Senator Baucus is being voted on today right?
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No I thought these were in addition to SGR. I may be wrong though.
 
i received this email from the AMA today.....im not sure what the agenda is, but they sure are trying to take credit for something in "our best interests".

Dear Todd:

We appreciate all that you've done on behalf of the Physicians' Grassroots Network. All of your hard work has paid off, because the Senate is about to consider a bill that would eliminate Medicare's sustainable growth rate (SGR) formula!

S. 1776, the "Medicare Physicians Fairness Act of 2009," was just introduced in the Senate this week. Senate leadership announced that the bill will serve as the Senate legislative vehicle for eliminating the SGR and laying the foundation for establishing a new Medicare physician payment update system. The bill would repeal the SGR permanently and set future payment updates at zero.

Importantly, the Senate leadership made it very clear that Congress does not intend to implement a permanent physician payment freeze and call it Medicare payment reform-and the AMA would not support such a proposal. Rather, by passing a separate bill that repeals the SGR and eliminates the accumulated spending target debt, budget constraints that have stopped permanent Medicare reform in the past would be lifted, allowing a new physician payment update system to be incorporated into a broader health system reform bill.

The first step to passing this bill will come quickly-as soon as Monday afternoon, in fact! On Monday, Oct. 19, there will be a "motion to invoke cloture." That means there will be a vote to allow formal consideration of the bill. The key thing to remember is that we need 60 senators to vote with physicians and vote YES on cloture.

A vote on final passage is expected to occur next Thursday (Oct. 22) or Friday (Oct. 23).

We're going to need your help three times in the next few days:

1. Call or e-mail Sen. Bill Nelson and Sen. George LeMieux NOW and urge them to SUPPORT S.1776. This bill would not only stop the Jan. 1, 2010, Medicare cuts of more than 20 percent, it also would repeal the flawed SGR payment formula and start us down the path toward ensuring that physicians can continue caring for Medicare patients. Use our hotline at (800) 833-6354.
2. Next week, there will be a second procedural vote on "waiving the budget act" for S. 1776. When the time comes, we will need you to contact your senators again and ask them to vote YES (don't worry, we'll remind you!).
3. When the bill itself is up for a vote, we will need one final phone call to both Sen. Bill Nelson and Sen. George LeMieux asking them to vote YES on S. 1776.

Each of these steps is critical to passing this bill, and Sen. Bill Nelson and Sen. George LeMieux need to hear from you at each point. Thank you for your continued involvement in the Physicians' Grassroots Network. Together we are stronger!
 
Mister Mxyzptlk said:
I don't see how they can do that unless CA law allows it. Signing a contract doesn't waive those legal rights. Otherwise we'd have all of our patients sign a contract agreeing not to sue us. Track down that law and see if you can use it too!
Click to expand...

Old thread, but learned something new recently.

Confirmed this recently with a malpractice defense attorney who has experience with Kaiser.

When a patient signs up with Kaiser, they agree to have disputes settled through arbitration.

If a physician has alot of complaints filed against them, I'm sure they get canned, but otherwise, another incentive to work for the man.:laugh:
 
Disciple said:
Old thread, but learned something new recently.

Confirmed this recently with a malpractice defense attorney who has experience with Kaiser.

When a patient signs up with Kaiser, they agree to have disputes settled through arbitration.

If a physician has alot of complaints filed against them, I'm sure they get canned, but otherwise, another incentive to work for the man.:laugh:
Click to expand...
Arbitration is also required with the VA and the military. Actually it's pretty amazing that even with all of these outrageously unfair advantages enjoyed by "not for profit" groups, there is any true healthcare market left. But there definitely is, despite all out efforts to stamp it out. And it will never die...

Viva la Free Market! If I had an AK47 right now I'd shoot into the sky like a crazy person...
 
Disciple said:
Old thread, but learned something new recently.

Confirmed this recently with a malpractice defense attorney who has experience with Kaiser.

When a patient signs up with Kaiser, they agree to have disputes settled through arbitration.

If a physician has alot of complaints filed against them, I'm sure they get canned, but otherwise, another incentive to work for the man.:laugh:
Click to expand...

The folks at the top in Kaiser are very, very smart. If Halvorson keeps the focus on evidence, outcomes, and good medicine it will be a good place to work. But - as with any big business - if the margin becomes the mission, it gets really ugly fast.

For me, life there near the end of my tenure there was quiet desperation.
 
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