Can you believe this???? Aetna.

[Tenesma]

Aetna considers any of the following injections or procedures medically necessary for the treatment of back pain; provided, however, that only one invasive modality or procedure will be considered medically necessary at a time.

Facet joint injections are considered medically necessary in the diagnosis of facet pain in persons with chronic back or neck pain (pain lasting more than 3 months despite appropriate conservative treatment).

Facet joint injections are considered experimental and investigational as therapy for back and neck pain and for all other indications.

A set of facet joint injections means up to 6 injections per sitting, and this can be repeated once to establish the diagnosis. It is not considered medically necessary to repeat facet joint injections more frequently than once every 7 days. Additional sets of facet injections are considered experimental and investigational because they have no proven value.


**** i find this out after i do facet injections on several aetna patients.... they tell me it is experimental and that I CANNOT bill the patient and that i will NOT be paid by Aetna.

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[Pain_doc]

Based upon what you wrote, did they pay at least for the one set of injections? I typically perform mbbs for diagnostic purposes, but its the same cpt code.

 

[Tenesma]

1) one patient gets an L4/L5 intra-artic facet every 6 months for the last 4 years with great relief

2) another one has severe rheumatoid arthritis who is on mega-doses of a ton of meds who gets fantastic relief of low back pain every 4 months w/ a right L3/L4 facet (very degenerated but i can get into the joint surprisingly) that has not responded to RF in the past (i suspect too much bony overgrowth to position needle well)...

argh.

 

[Mister Mxyzptlk]

They are telling you to do RF I guess.

I just got a denial for MBBs because the pain "radiates" to the gluteal area and upper thigh. Based on their criteria, back pain with radiation requires an MRI before facet injections can be done.

Welcome to the Bizarro World. I wonder what happens if they have both radicular and joint problems. Does radiculopathy protect against facet pain?

I also got a denial from Humana for a repeat ESI because we have to wait 2 months.

 

[Tenesma]

well ... here is the best part for aetna

my 3rd denial:
patient had 2 diagnostic medial branch blocks with both >90% relief... i wanted to do an RF --- they said that since she didn't have 6 months of pain, they wouldn't approve the RF... well, she had 5 months of pain --- she is a lawyer s/p gastric bypass and can't take NSAIDS, refuses any sedating medication, and is not doing better w/ PT, acupuncture, chiropractic and is miserable... so i go ahead and do an intra-articular facet to hold her over until the lumbar RF ---- she has had complete relief for 4 weeks now (just saw her yesterday) -- got the aetna denial today because that intra-articular facet injection is "experimental" since she already had 2 blocks... so what am i supposed to do w/ facet mediated pain that lasts >3 months <6 months??? they couldn't answer that --- in fact, one of their reps told me that the patient should wait until the pt satisfies the 6month issue for the RF to be authed...

 

[DOctorJay]

Time to go cash based and let the patients deal with the headache. Then things will change as they will finally make noise for real healthcare reform.

 

[Sandpaper]

I also got a denial from Humana for a repeat ESI because we have to wait 2 months.

Yup, not only that, but the patient must have obtained >50% pain relief in order for them authorize a repeat injection. Oh how I love Humana.

 

[SleepIsGood]

Time to go cash based and let the patients deal with the headache. Then things will change as they will finally make noise for real healthcare reform.

Interesting concept.

Somehow thy'll spin this as 'docs chrge too much'.

Ridiculous!

 

[deleted185747]

I have a physician friend who just had a hair transplant and he paid several thousand dollars for it. Boob job costs $3000 and people pay out of pocket.

I guess with elective things like hair transplant and cosmetic/plastic surgery there is more acceptance by the public to pay big $$$

For back pain the same mentality somehow dissolves...

 

[Tenesma]

issues w/ cash based practice that is NOT a pill mill

1) pts are hurting, are losing their job, are usually on some type of financial precipice --- it rarely is the same population forking over cash for aesthetic procedures
2) pts are hurting and don't care who treats them as long as SOMETHING gets done, and will just go to competitor for their treatments

then again, i just had a patient on disability who spent $4,000 on Vax-D/DX9000/crap table at a chiropractors office and was complaining that i had requested that he pay his balance in full for his next visit ($7.42)....

argh

 

[stim4u]

all pain doctors on this forum should keep appealing and take these insurances to the state health commisioner. I recently took anthem to the commisioner, after 3 appeals. they had an independent pain guy review and uphold my treatment. now anthem has a strike on their backs and all my RFA's are going through once again. we need to keep strong, or they will keep skrewing with our authorizations and reinbursement......

 

[Tenesma]

i have spoken at length with aetna... and their explanation actually makes sense to me.

1) they are a benefit provider --- people/employers pay premiums in order to obtain medical care at a discounted rate...

2) if i believe that a patient would benefit from a service, that is my medical decision and is between me and the patient... they don't want to dictate my care. However, they are only going to pay for those things that they feel is beneficial and all other treatments are at the discretion of the patient.... just like they don't pay for lyrica for postlumbar laminectomy syndrome and they don't pay for acupuncture for migraines...

3) when it was explained to me in that way, it made complete sense... still pisses me off though...

4) i broached the issue with those aetna patients who love their facets and guess what 8 patients so far have agreed to pay cash upfront for their facet injections (!)

at a higher rate than aetna would have paid me...

hmmmm.... maybe this is a good thing?

 

[lobelsteve]

i have spoken at length with aetna... and their explanation actually makes sense to me.

1) they are a benefit provider --- people/employers pay premiums in order to obtain medical care at a discounted rate...

2) if i believe that a patient would benefit from a service, that is my medical decision and is between me and the patient... they don't want to dictate my care. However, they are only going to pay for those things that they feel is beneficial and all other treatments are at the discretion of the patient.... just like they don't pay for lyrica for postlumbar laminectomy syndrome and they don't pay for acupuncture for migraines...

3) when it was explained to me in that way, it made complete sense... still pisses me off though...

4) i broached the issue with those aetna patients who love their facets and guess what 8 patients so far have agreed to pay cash upfront for their facet injections (!)

at a higher rate than aetna would have paid me...

hmmmm.... maybe this is a good thing?

It is the end of the beginning. The dentists did this a long time ago We will slowly drop out of insurance filing and find ourselves spending 2 more hours per day with patients or family as we will no longer be involved in PA/precert, and explaining to third parties what should get done. Patient satisfaction will increase and malpractice premiums will drop. Then we will drop off MC rolls and the sky will fall.

 

[Jcm800]

I have a physician friend who just had a hair transplant and he paid several thousand dollars for it. Boob job costs $3000 and people pay out of pocket.

I guess with elective things like hair transplant and cosmetic/plastic surgery there is more acceptance by the public to pay big $$$

For back pain the same mentality somehow dissolves...

did he get the boob job to accent the new hair?

 

[DOctorJay]

cash at time of service, fill out and give patient CMS 1500 form

 

[mid|ine]

I guess with elective things like hair transplant and cosmetic/plastic surgery there is more acceptance by the public to pay big $$$

The thing that gets me is the pts that come in and tell me how they spent $2000 on a traction treatment at the chiro down the street and then come in and complain about their co-pay...

 

[pjuer]

issues w/ cash based practice that is NOT a pill mill

1) pts are hurting, are losing their job, are usually on some type of financial precipice --- it rarely is the same population forking over cash for aesthetic procedures
2) pts are hurting and don't care who treats them as long as SOMETHING gets done, and will just go to competitor for their treatments

then again, i just had a patient on disability who spent $4,000 on Vax-D/DX9000/crap table at a chiropractors office and was complaining that i had requested that he pay his balance in full for his next visit ($7.42)....

argh

Most of them don't have problems paying cash for their hydrocodone or oxy either

 

[pjuer]

If it gets any worse, I may just become a medical acupuncture clinic for cash only. No Rx's to write, minimal med mal risk, and I could eliminate 90% of my employees and overhead.

 

[hyperalgesia]

i have spoken at length with aetna... and their explanation actually makes sense to me.

1) they are a benefit provider --- people/employers pay premiums in order to obtain medical care at a discounted rate...

2) if i believe that a patient would benefit from a service, that is my medical decision and is between me and the patient... they don't want to dictate my care. However, they are only going to pay for those things that they feel is beneficial and all other treatments are at the discretion of the patient.... just like they don't pay for lyrica for postlumbar laminectomy syndrome and they don't pay for acupuncture for migraines...

3) when it was explained to me in that way, it made complete sense... still pisses me off though...

4) i broached the issue with those aetna patients who love their facets and guess what 8 patients so far have agreed to pay cash upfront for their facet injections (!)

at a higher rate than aetna would have paid me...

hmmmm.... maybe this is a good thing?

Awesome. This has always been between us and the patients. Tenesma, your practice is looking more and more like the ultimate model. My idol

 

[Tenesma]

cash at time of service, fill out and give patient CMS 1500 form

that is illegal...

 

[DOctorJay]

that is illegal...

sorry, I meant for the CMS 1500 to be given to the patient to be sent to private insurance which should reimburse the patient, NOT medicare which I agree is illegal.

I've seen this recommendation on another forum, if this is incorrect please inform.

 

[powermd]

that is illegal...

Forgive my ignorance, but I know enough not to assume even that when things make perfect sense to me, they are in fact legal. But is it illegal to allow a Medicare patient to pay cash for any procedure that would otherwise be covered by Medicare? For example, the patient wants an ESI the day of a NP consult- not in 24 hrs when Medicare allows you do do a procedure.

 

[Tenesma]

while the patient may pay cash... you are doing something illegal by accepting the cash for a covered service through medicare if you are a participating provider.

if you are out of network w/ medicare which is different from non-par, you may take the cash, but it is illegal for the patient to submit their claim to medicare if it is a covered service ... thus the ABN that you have the patients sign.

bottom line.... medicare fraud involves treble fines and/or jail time and loss of medicare privileges which will royally screw your career over as most private payers and hospitals will drop you like a dirty rag....

don't mess w/ the feds...

 

[Mister Mxyzptlk]

i have spoken at length with aetna... and their explanation actually makes sense to me.

1) they are a benefit provider --- people/employers pay premiums in order to obtain medical care at a discounted rate...

2) if i believe that a patient would benefit from a service, that is my medical decision and is between me and the patient... they don't want to dictate my care. However, they are only going to pay for those things that they feel is beneficial and all other treatments are at the discretion of the patient.... just like they don't pay for lyrica for postlumbar laminectomy syndrome and they don't pay for acupuncture for migraines...

3) when it was explained to me in that way, it made complete sense... still pisses me off though...

4) i broached the issue with those aetna patients who love their facets and guess what 8 patients so far have agreed to pay cash upfront for their facet injections (!)

at a higher rate than aetna would have paid me...

hmmmm.... maybe this is a good thing?

This has been their stock answer for years. "We are not saying the patient can't have the procedure. We are simply refusing to pay for it. We're just the arbiters of the benefits."

While true, for many patients the end result is the same - no treatment.

I must admit it's a very slick cop-out, and they have a system where people pay them in advance and then hope they are covered for whatever unforeseen events affect them later. Actually they naively expect coverage and then find out that after a stroke they can have 10 sessions of PT. How many of you can make heads or tails out of your health insurance policy?

As for going to cash-only, many people with insurance are functionally cash-only due to their high deductible and OOP allowances. That will only get worse.

 

[PMR 4 MSK]

The problem I have always had is when the insurance company ssays this is not a coverred procedure and you cannot bill the patient either. This is usually with HMOs.That is pure BS. the patient and I agreed on a service, he has a contract with an outside company to pay what they will cover. How can they tell me I cannot bill the patient when they wont cover?

Yes, I know they can, but it is still BS.

Agree with don't mess with Medicare, they will put you in federal pen.

 

[Tenesma]

mister... amen brother...

i purchased the BEST (ie: most expensive) health insurance for me and my family... and I am still amazed when my wife or children get medical attention (i have one kid with a lot of medical bills) at 1) the crap pre-auths i have to fight about (thank god i am a doctor and can argue my way up their food chain) 2) the amount of medical costs that aren't covered (what is covered by a deductible, what falls into a co-insurance, oh... you didn't meet your out of pocket expenses yet because the deductibles and co-insurances don't apply to out of pocket expenses....)... it is absolutely ridiculous...

 

[SSdoc33]

careful, you three. you might just be arguing FOR a government-run plan....

 

[Mister Mxyzptlk]

All the insurance company can do is say whether or not it's a covered benefit. They can't prohibit the procedure. All they can do is refuse to pay for it. This goes for Medicare too as long as you execute an ABN first.

 

[PMR 4 MSK]

All the insurance company can do is say whether or not it's a covered benefit. They can't prohibit the procedure. All they can do is refuse to pay for it. This goes for Medicare too as long as you execute an ABN first.

But that is not entirely true - as above, they can and do say that something is not a covered benefit and "member does not owe" meaning by the contract you have with them, you cannot balance bill the patient.

 

[Tenesma]

pmr... you are right, you cannot balance bill the patient UNLESS you can document that you discussed with the patient first that this procedure is not-covered and that they have to pay upfront....

 

[DOctorJay]

that is illegal...

"In its purest form, cash-only practice means not participating with any insurer; however, the practice may provide insured patients with a completed CMS-1500 form to enable them to file their own claim. This arrangement generally enables much lower overhead because claims processing, patient billing and countless hassles related to managed care can be eliminated."

http://www.aafp.org/fpm/2006/0200/p61.html

 

[Jcm800]

"In its purest form, cash-only practice means not participating with any insurer; however, the practice may provide insured patients with a completed CMS-1500 form to enable them to file their own claim. This arrangement generally enables much lower overhead because claims processing, patient billing and countless hassles related to managed care can be eliminated."

http://www.aafp.org/fpm/2006/0200/p61.html

is it feasible to go cash based and be interventional based? i doubt most patients will pay 400 bucks for an ESI? is it possible to do cases at a hospital or surgery center, where the facility DOES participate in the patients insurace BUT YOU DO NOT...

so you say its 250 for the ESI, we do it at the faciltiy, the facility takes whatever they get in or out of network, and you collect ahead of time, like a plastic surgeon.

in the office medicare typically pays like 290 bucks after flouro for a single level TFESI, and like 380 or whatever for a 2 level or bilateral. Would your patients pay this? i dont think mine would. so then you woud have to cut your rates, but your overhead stays high, so are actually making less money...

which is why i think the cash pay model will only work for medical-management, i suspect. THoughts?

 

[hyperalgesia]

In our society, people are not used to paying for healthcare anymore. It is their God-given right, along with their "right" to own a house. Don't get me started...
Anyway, if you don't "accept" their insurance (basically deal with all the cost issues), except for a small copay, they will find someone who does, if they can. But there are other factors to consider. If you have a strong referral setup or an incredible marketing dept, you have a lot more leverage. I'm in an area where there is a lot of competition in the pvt sector. Medicare is generally the best payor and there are HMOs that get away with paying 70% of Medicare rates to the physicians. But I had a patient come to me at the VA asking for a LESI. Rather than wait 5 days and get it for free, he chose to go to his pvt pain doc and pay $1000 to get it the next day. Yes, $1000 cash for a LESI. No insurance or Medicare accepted. This particular pt had already had one LESI in a series (paid 1k for that) and was interested in a second.
I know other pain docs in the area who are well-trained and established but feel they have to accept any form of payment that walks through the door. So anything is possible.

 

[Mister Mxyzptlk]

Many insured patients are functionally cash patients because of the ever-increasing deductibles and out-of-pocket requirements. You can pay $1,500/month and get a $2,500 deductible and then 60/40 up to $5,000. You might as well just have a catastrophic coverage policy.

 

[PMR 4 MSK]

Many insured patients are functionally cash patients because of the ever-increasing deductibles and out-of-pocket requirements. You can pay $1,500/month and get a $2,500 deductible and then 60/40 up to $5,000. You might as well just have a catastrophic coverage policy.

If you talk to most rational people, all they want is to be covered for catastrophy.

I think that's all anyone should have - $3 - 5 K deductable and then 100% coverage. Government could subsidize the poor and employers could offer their own subsidies as a incentive to get good employees. Couple it with a Health Savings Account that is tax deductible and you really get people motivated to watch their healtch care dollars.

 

[Tenesma]

more and more patients are on these plans and realize that they are on the hook for up to 5k.....

HOWEVER, those plans do NOT allow me to collect their deductibles up front until their ins. processes their claim.... at which point, they usually are NOT interested in paying me what is owed and come up with all kinds of excuses...

so now I have to come up with creative ways to collect up front... ie: i don't charge a deductible up front, but take a "deposit" to schedule their procedure....

 

[PMR 4 MSK]

Thats what hospitals often do. We should all do the same.