Reimbursement for b&b pain procedures

[W222]

What do you get for an Esi? Facet injections? Ablation? I am trying to formulate some basic numbers for a proposal.

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[ultm8frisbee]

http://www.asipp.org/documents/Physcians2012FinalasofDec202011.pdf

 

[PMR 4 MSK]

It totally depends on your contracts and how many patients are under each contract. I've seen ESI's pay anywhere from $80 to $3000.

A good way to do it is to take CMS #'s, like above, multiply by 1.5-2, and call that the private insurance #'s. But I have some insurers paying 5x CMS on some procedures. Others 1.2.

 

[mid|ine]

It totally depends on your contracts and how many patients are under each contract. I've seen ESI's pay anywhere from $80 to $3000.

A good way to do it is to take CMS #'s, like above, multiply by 1.5-2, and call that the private insurance #'s. But I have some insurers paying 5x CMS on some procedures. Others 1.2.

How the hell are you getting those contracts? We have a lot of 1 and 2 doc shops around the area getting LESS then CMS (0.8-0.9) for pain work from private insurers. I though our group had very favorable contracts (>>1x CMS).

 

[PMR 4 MSK]

How the hell are you getting those contracts? We have a lot of 1 and 2 doc shops around the area getting LESS then CMS (0.8-0.9) for pain work from private insurers. I though our group had very favorable contracts (>>1x CMS).

We are the 800# Gorilla in town. Soon to be 25 docs. CEO used to work for the Dark Side - an insurance company. We wait for the insurance companies to come to us with a decent offer.

 

[W222]

So based on the CMS numbers and the fact that >80% of my patients will have private insurance, what is likely reimbursement? Atleast even with CMS or slightly above?

 

[emd123]

We are the 800# Gorilla in town. Soon to be 25 docs. CEO used to work for the Dark Side - an insurance company. We wait for the insurance companies to come to us with a decent offer.

WTF? 25 Pain guys or multispecialty? How many Pain, how many "other"?

 

[bedrock]

So based on the CMS numbers and the fact that >80% of my patients will have private insurance, what is likely reimbursement? Atleast even with CMS or slightly above?

It can vary greatly depending on their private insurer contracts. Use the ASIPP data from the first reply as a base as this represents general CMS numbers. Ask your prospective employer/partner "what percentage over medicare are they paid" for their top 5-10 insurers. The ask them to supply tell you what percentage of their patients come from each of those top 5-10 insurers. Do the math and you'll have a rough idea.

What percent over medicare a practice may be paid varies greatly from area to area and depends on the strength of the insurance contracts your prospective partners have.

So much of this legwork you have to do yourself because these situations can differ greatly from state to state and even in the same city depending on whether your prospective practice is the 800lb gorilla or consists of 1-2docs.

 

[PMR 4 MSK]

WTF? 25 Pain guys or multispecialty? How many Pain, how many "other"?

2 PM&R/pain
3 Rheum - looking for 4th
2 Podiatry
2 FP - 1 sports, 1 urgent care

The rest ortho. All but one of the orthopods are fellowship trained, and he doesn't do surgery any longer, just general ortho 2 days/wk.

We have 3 hand docs, 4th coming this summer.
2 sports med ortho, 3rd coming this summer
3 Joint replacers, 4th coming this summer
3 trauma
1 peds
1 spine ortho starting this summer

So I mis-counted, we'll have 26 docs this summer

 

[emd123]

2 PM&R/pain
3 Rheum - looking for 4th
2 Podiatry
2 FP - 1 sports, 1 urgent care

The rest ortho. All but one of the orthopods are fellowship trained, and he doesn't do surgery any longer, just general ortho 2 days/wk.

We have 3 hand docs, 4th coming this summer.
2 sports med ortho, 3rd coming this summer
3 Joint replacers, 4th coming this summer
3 trauma
1 peds
1 spine ortho starting this summer

So I mis-counted, we'll have 26 docs this summer

Awesome. That's strong. The way things are looking for the future of healthcare, there is strength in numbers.

 

[Louisville04]

2 PM&R/pain
3 Rheum - looking for 4th
2 Podiatry
2 FP - 1 sports, 1 urgent care

The rest ortho. All but one of the orthopods are fellowship trained, and he doesn't do surgery any longer, just general ortho 2 days/wk.

We have 3 hand docs, 4th coming this summer.
2 sports med ortho, 3rd coming this summer
3 Joint replacers, 4th coming this summer
3 trauma
1 peds
1 spine ortho starting this summer

So I mis-counted, we'll have 26 docs this summer

How come you have only one spine ortho? It seems like everyone has back pain. Is there a shortage of spine ortho/neurosurgeons? It is difficult for the VA to recruit them due to financial constraints.

 

[bedrock]

How come you have only one spine ortho? It seems like everyone has back pain. Is there a shortage of spine ortho/neurosurgeons? It is difficult for the VA to recruit them due to financial constraints.

Probably good for the VA patients..... If only the truly needy patients make to the spine surgeon.

 

[PMR 4 MSK]

How come you have only one spine ortho? It seems like everyone has back pain. Is there a shortage of spine ortho/neurosurgeons? It is difficult for the VA to recruit them due to financial constraints.

Several years ago, we had 2, but they fought with the other orthopods over call - didn't want to take general call - i.e. didn't want to fix broken hips at 2 am. One quit and the other left soon after, they formed their own group and everyone got a long better. We've been referring to them for years, but it left a sour taste in the orthopods mouths here. I've been pushing for a spine ortho for years, mostly met with resistance. We almost had one, but then his credentials were not what he said and he could not get spine priviledges locally.

Our town has no shortage of spine docs. 150K population in town, 400K catchmant. 3 fellowship-trained ortho spine. At least 6 neurosurgeons who all do spine, and a few older ortho docs who still do some spine (but not very well).

One of the problems our group has had is getting someone to have cross-coverage for spine, as required by hospitals. None of the other spine guys in town would agree to cover their competition.

 

[lobelsteve]

How come you have only one spine ortho? It seems like everyone has back pain. Is there a shortage of spine ortho/neurosurgeons? It is difficult for the VA to recruit them due to financial constraints.

They only need one because their pain docs are A1+.

 

[Disciple]

One quit and the other left soon after, they formed their own group and everyone got a long better. We've been referring to them for years, but it left a sour taste in the orthopods mouths here.

That's odd. Why does your group still refer to them then? or was that pre joining the group and subsequent break-up?

 

[PMR 4 MSK]

That's odd. Why does your group still refer to them then? or was that pre joining the group and subsequent break-up?

It was a professional-personal thing. Professionally, they are very talented surgeons. Since leaving our practice they've done surgery on a couple of our docs, and several family members of our docs. They are not only good at surgery, but are good with the patients as well.

OTOH, they could not get along with the other surgeons. Orthos already have high opinions of themselves, and sometimes the halls get a little too small for that many inflated egos. There were shouting matches and hissy fits too often, and all agreed they would do better with a divorce. The big sticking point was general call, which resulted in a we-vs-they situation, the staff members started bickering as well, etc.

It was an amicable split, at least at the end, but not without some hurt feelings, especially when it came to money. If you think a man vs woman divorce can get heated over money, try watching a group of surgeons who have invested their entire lives, careers and fortunes to each other get divorced. However, once the money situation is agreed upon, everyone walks away happy and can shake hands and mingle at Christmas parties. There is no love lost, but at the end of the day, you still want your patients treated by the best doctor you know.

I may not want to socialize or partner with certain docs, but I will have no problem referring them patients when they are the best choice.

 

[bedrock]

I may not want to socialize or partner with certain docs, but I will have no problem referring them patients when they are the best choice.

Was that the guy who did a two-level fusion on the 40 year old with a L4-L5 disc herniation?

 

[PMR 4 MSK]

Was that the guy who did a two-level fusion on the 40 year old with a L4-L5 disc herniation?

No, different group. That guy was a neurosurgeon.