For all the Alarmist talk

lonelobo

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    Newsletter from Anesthesia Business Consultant

    Conversion Factor

    The general Medicare conversion factor, which applies to pain medicine, critical care, evaluation and management and other “flat fee” services, will decrease by 20.1 percent, to $27.2006. In March 2013, CMS had projected a CF decrease of 24.4 percent for 2014.

    The announcement of a decrease should not raise an alarm: we are all accustomed to the annual two-step dance in which CMS applies the statutory Sustainable Growth Rate (SGR) formula, resulting in an arithmetic reduction, and then Congress overrides the cut in last-minute legislation.

    In its explanation of the calculation of the new CF, CMS made clear its dislike for the reduction that the SGR compels:

    By law, we are required to make these reductions in accordance with section 1848(d) and (f) of the Act, and these reductions can only be averted by an Act of Congress. While Congress has provided temporary relief from these reductions every year since 2003, a long-term solution is critical. We will continue to work with Congress to fix this untenable situation so doctors and beneficiaries no longer have to worry about the stability and adequacy of payments from Medicare under the Physician Fee Schedule. The Senate Finance Committee has scheduled a December 12 "open executive session" on the draft bipartisan proposal that would repeal the SGR and replace it with a mix of payment freezes and alternative payment models that reward physicians with bonuses for value and quality rather than volume
     

    emd123

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      I hope you're right, that the leaked fee schedules I posted on the 2014 Billing Update thread are all underestimated by -20% per procedure and include the SGR.

      If so, that means ESIs are only down 31-38% (not 51-58%), RF is up 20% and that everything else is up by 12-16% (instead of down 4-8%) across the board. I pray that what you are implying is right, but somehow I just don't see it happening, that they are going to just cut esi's then give us completely unexpected across the board increases in everything else.

      In today's reimbursement environment, I find it easier to believe that across the board drastic cuts will happen, as opposed to cuts in some areas and increases in anything, to provide balance.

      I seriously hope you are right though. And I think it's absurd that 12 days later, were still left kicking around rumor when we have, what, 4 or 5 societies that claim to be "Pain Societies" that some of us pay dues to, to do this work?

      FWIW, before I posted the leaked fee schedule, I specifically asked if it included the proposed SGR cut (which I know never gets enacted), and I was told it did not. Unfortunately, the stim leak turned out to be 100% on the money of course, from the same source.

      Again, where is ASIPP on this?

      We need them to confirm or deny all of this. This is part of what we pay them for.

      I can't tell you how happy I'll be if what you are saying is correct, and that the leaked fee schedule I posted is wrong, and that the real fees are 20% higher.
       
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      hotroddin

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        Unfortunately, I believe ya'll are talking 2 different things here. 1. Yes, the conversion factor may not go down if congress acts as noted in first post. 2. This is specifically addressing the conversion factor which is totally different than the RVU which was released on the CMS site that showed the dramatic cuts granted it does state 2014 Final with Comment Period as noted in posts elsewhere on forum. This is explained below.




        Work RVU1 x Work (GPCI)2

        +
        Practice Expense (PE) RVU x PE GPCI

        +
        Malpractice (PLI) RVU x PLI GPCI


        = Total RVU

        x
        CY 2013 Conversion Factor of $34.023


        = Medicare Payment
         
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        emd123

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          Cuts are confirmed by ASIPP now, to include the higher $34 conversion factor, and SGR not being cut. If the SGR is not fixed, and the conversion factor in the OP goes into effect, they will be even lower. They are final. There will be no magic fix. See 2014 Billing update thread.

          http://www.asipp.org/documents/Physicians2014F.pdf

          Buckle up.
           
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          stim4u

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            Cuts are confirmed by ASIPP now, to include the higher $34 conversion factor, and SGR not being cut. If the SGR is not fixed, and the conversion factor in the OP goes into effect, they will be even lower. They are final. There will be no magic fix. See 2014 Billing update thread.

            http://www.asipp.org/documents/Physicians2014F.pdf

            Buckle up.
            buckle up.... if these rates go into effect it is the death of pain management, private practices and the specialty as whole. who the hell is going to perform an in office LESI/CESI for $100???? crazy.
             

            Ligament

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              Will somebody with some self restraint explain to me what this crap means? I am unable to read the document without getting violent. All I see are major cuts on everything we do. Especially epidurals. NO way I'm doing a cervical epidural for $70 fcking dollars!!!!!!
               

              lobelsteve

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                Will somebody with some self restraint explain to me what this crap means? I am unable to read the document without getting violent. All I see are major cuts on everything we do. Especially epidurals. NO way I'm doing a cervical epidural for $70 fcking dollars!!!!!!

                It means you want to get a big salary and work in an RVU model until things change or the sky does fall on IPM. Or we can retrain as attorneys. Look for other revenue streams outside of seeing patients. Chart reviews, legal reviews, non-medical potential income. I'm going pro and will start racing in IMSA (not bloody likely).
                 

                Ligament

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                  Here is the email I got from ASIPP on this issue:

                  December 10, 2013


                  Dear Ligament :

                  Usually around this time we panic about sustainable growth rate (SGR) cuts which are scheduled to be 20% pay cut again unless congress fixes it temporarily or permanently. However, we have a much bigger problem this time.


                  As a Thanksgiving gift on November 27, 2013, Centers for Medicare and Medicaid Services (CMS) posted the 2014 final rules for physician payments as well as hospital outpatient and ambulatory surgical center payments the day before Thanksgiving. New rates will be effective January 1, 2014.

                  It is all about universal health care and administration attempts to go to single payor system with consolidation of hospital industry with elimination of physician practices. [thanks Obama supporters!!!!!!!!!]

                  • This may put 40% of pain physicians out of practice
                  • Reduce access to care
                  • Increase Medicare expenses by $187 million.
                  It is an understatement to say that the cuts are draconian and it will be devastating. Unless we act upon the issue this may be the end of interventional pain management practice for almost 40% of the physicians who base majority of their practices out of office setting.

                  With these unforeseen reckless cuts, we have entered the perfect storm. We are no longer over the cliff, we are in deep waters. This is not an exaggeration. The cuts for physician payment for cervical and lumbar epidural injections in the office setting are 58 and 51% respectively and, and also significantly reduced in the ASC/Hospital as well 36 and 23 % respectively. This does not include the potential 20% SGR cuts. This will also likely shift care into more expensive sites of services setting, namely hospitals and ASC's and have devastating effects on physician reimbursement. This will further empower hospitals under Affordable (Obama) Care.

                  Recently we have been hit with multiple problems:

                  1.Noridian developed national local coverage determinations (LCDs) and threat of national coverage determinations (NCDs) with severe restrictions.
                  2. Cigna and other insurance coverage issues essentially are limiting interventional pain management either in duration or indications.
                  3. The usual threat of SGR cut of 20.1%.
                  4. ICD-10, RACs, OIG, single-dose vials, EHRS, and continuing expansion of HIPAA

                  5. Now the mother of all, physician payment final rule for 2014 with whopping cuts -- we are facing as high as 36% for physician payment and over 58% when the procedure is performed in an office for most commonly performed procedures - namely epidural injections (CPT 62310, 62311, 62318, and 62319). We are also facing some cuts for transforaminal epidural injections as well as facet joint interventions; however, these are much less compared to caudal or interlaminar epidural injections.

                  Essentially, hospitals will be reimbursed at $669.90 for the epidural procedure performed in the hospital setting; whereas, in office setting, after removing the portion designated for the physician professional fee, office practice expense will be reimbursed at $30.28 to $34.36 a whopping 2,315% to 2,668% with SGR cut and 1931% to 2312% without SGR cut more in the hospital setting.

                  Other cuts are related to spinal cord stimulators. When trials are performed in an office setting, starting January 1, 2014, there will also be a huge reduction in reimbursement approaching 60% for a single lead and 75% for a dual lead trial. While CMS will continue to reimburse under Medicare with CPT code 63650 and expected to be reported for each lead insertion procedure and trial, L8680 will no longer be reported for the device component. The new global payment in the office setting for 63650 has been reduced to $1,281.65 nationally. A 50% modifier will still be applied for a second lead in a dual lead trial.

                  In the proposed rule, as well as in the final rule CMS also has erroneously considered percutaneous adhesiolysis - 1 day (CPT 62264) similar to ambulatory surgery center (ASC) moving it from neurolytic blocks APC group to epidural and facet joint Ambulatory Payment Classification (APC) group reducing the payment to epidural levels in hospital as well as in ambulatory surgery center settings. For many hospitals this may be okay because these are performed in a small room, without all the expenses ASCs have to go through, but it continues to be devastating for offices and represents a significant disadvantage for ASCs.

                  Remember, this does not include the possible 20.1% cut expected for implementation of SGR.

                  Make no mistake - this will be followed by every carrier nationally.

                  This will again lead to explosion of pill mills

                  All of the details are provided in the fact sheet.

                  It is time to act now. If you do not act now, probably you will never have an opportunity to act later.

                  You are the best lobbyist for yourself and for IPM and your office is the lobby central. Immediately without wasting a single minute start advocacy on behalf of yourself, your patients, and your staff for the future of interventional pain management.

                  Based on the available information, as of now:


                  • The RUC process showed decreased times, but did not involve all stakeholder physician groups. Even then, the AMA RUC recommended continuing the same payment schedule. (I.e. - these changes were made by CMS and not the RUC in large part.
                  Data was available in 2012, yet the proposed schedule in July did not include the proposed cuts.

                  Consequently, there was no comment period even though it is required.
                  • Medicare has not taken into consideration Medicare Economic Index (MEI) which has been increasing substantially. Now the gap with SGR cuts will be 90% and without SGR cuts will be 70% between expenses and the revenue.
                  • Medicare has not taken into consideration MedPAC concerns of a widening gap between hospitals and physician payments and specific recommendations for CMS to address these issues.
                  • Hospitals have increased their payment by almost 20% for the same procedures, whereas in-office procedures are facing almost a 60% cut, with no change in operational expenses (and the threat of SDV causing increased costs of care
                  • In fact, moving these procedures from in an office setting to hospital outpatient department (projected to move at least 80%), will increase the costs so substantially that the patient copay itself is 4 times higher than the entire payment in an office setting, and was equivalent to full payment with proposed rates.
                    • In addition, the total costs of these procedures will increase based on 2011 statistics which showed 412,799 of 1,114,458 epidurals (only 2 codes 62310 and 62311) were performed in office setting in Medicare population. If 80% of these procedures (330,239) were performed in HOPD setting, the cost of these 2 procedures increased over $187 million per year considering the reimbursement in the proposed rule of $85-$105 per procedure
                  • This may even lead to with kickback as hospitals receiving much higher facility payments and offering physicians occasionally a portion of these revenues, which will lead to troubles at a later date.
                  • This change will also fuel pill mills with increasing deaths.
                  • Consequently, we request Congress to act swiftly and decisively to request Medicare withdraw the proposed final rule for the family of codes 62310-62319 and allow the public time to comment, as required within the Medicare Integrity Manual, before implementing more reasonable changes in 2015.
                  Click here for 2014 Final Physician Fee Schedule.

                  We have set up Capwiz letters for physicians and patients. You should customize and describe your own situation in physician letters. Make sure each and every physician writes a letter. Even physicians who are not interventional pain physicians may write them

                  Capwiz Letter for Physicians

                  Capwiz Letter for Patients

                  You should customize and describe your own situation in physician letters. Make sure each and every physician writes a letter. Even physicians who are not interventional pain physicians may write them.

                  This should be followed by all your staff members, their relatives and friends.

                  Finally, the most important aspect is the access to care, so we have to get our patients involved as our partners in this survival journey. It is not just the patients, but their family members and their friends.

                  Please go to ASIPP Web site for more information on how to start your letter-writing campaign.

                  We need to work on this issue vigorously and with full force. Justice is on our side, interventional pain management is not experimental, it is essential and evidence-based. We have to protect the access to all Americans.

                  Fighting these issues cost significant money and funding this battle is essential. As you all know, ASIPP spends all its money on the business of preserving interventional pain management. Consequently, we request you to contribute liberally to Save IPM campaign (Save IPM fund).

                  Register for the Annual Meeting (brochure).Hopefully, issues will be resolved by then.

                  Thank you. Start acting immediately. If you have any further questions, please feel free to contact us.




                  Hans C. Hansen, MD

                  President, ASIPP

                  Medical Director

                  The Pain Relief Centers, LLC

                  224 Commerce St

                  Conover, NC 28613

                  Phone: (828) 261-0467

                  Fax: (828) 261-7293

                  [email protected]







                  Laxmaiah Manchikanti, MD

                  Chairman of the Board and Chief Executive Officer, ASIPP

                  Medical Director, Pain Management Center of Paducah

                  Clinical Professor, Anesthesiology and Perioperative Medicine

                  University of Louisville, Kentucky

                  2831 Lone Oak Road

                  Paducah, KY 42003

                  Phone: 270-554-8373 ext. 101

                  Fax: 270-554-8987

                  [email protected]


                   

                  bedrock

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                    It means you want to get a big salary and work in an RVU model until things change or the sky does fall on IPM. Or we can retrain as attorneys. Look for other revenue streams outside of seeing patients. Chart reviews, legal reviews, non-medical potential income. I'm going pro and will start racing in IMSA (not bloody likely).

                    Must admit that working in an RVU model is looking all the more appealing, (which is very depressing to say)
                     

                    Ducttape

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                      The huge effect is that IPM is to be done in ASCs or HOPD. PP is hosed unless volume goes up.


                      Then again, it might serve to reduce the number of those poser doctors who aren't really pain doc who are billing for IPM.


                      I wonder how many of the top 1-2% salary wise do stuff in office based practice vs. ASC ...
                       

                      Ligament

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                        December 11, 2013


                        Dear Ligament :



                        We sent you a letter yesterday along with a fact sheet which can be found at the top of this letter and on the ASIPP homepage, however, today we wanted to talk to you about how to successfully lobby on this issue.



                        ASIPP has a Capwiz account for our members because it is the most efficient and effective way to send the letters.



                        Please don't stop at sending your own letter, or even 2 or 3 other letters. Each physician should make a conscious effort and send minimum of 500 and as many as 2,000 per physician. Obviously this will mean if there are 10 people in your group minimum will be 5,000, and may be able to send as many as 20,000 or so. It is extremely important that we send as many letters as possible. Here is the process:



                        Computerized Signatures:

                        The traditional way is to divide the patients into the state and congressional district in which they live. Following this you put one letter for each congressional district and state. This letter will be addressed to CMS, congressman, and both the senators.



                        If you have patients from 4 states, you need to have 4 different types of letters based on their congressional offices. If your patients come from 10 congressional offices, you will have 10 different letters. Click here for an example for the KY 1st District letter.



                        Show the patient this letter and if they are willing to sign make sure they provide their address, phone number, e-mail, etc. as we have shown in the example letter above.



                        Preferably that same day one of your staff members will enter all the names along with the addresses using the patient letter Capwiz link. This will produce a customized letter to CMS, the member of the congress, and to both senators as one letter. If you have personnel onsite to do this, this is the best approach. You can ask the patients, their attendants, staff, and each and every one to sign on to the computer itself.



                        You should keep the addresses, etc. of the person who is signing the letter and after making a copy to keep, mail one to each addressee. Again, this may not reach the authorities on time and no action may be taken. However, if this is the only way you can do this. As the saying goes, doing something is better than doing nothing. We will always be ahead of the one who is doing nothing at all.



                        Let us get to work. We will be monitoring the number of letters going. All the letters going through ASIPP website will be known to us; however, if you send them outside we will not know about them. You may want to send us a copy of those letters.




                        Capwiz Link for Pysician Letters

                        Word Version for Physician Letters



                        Capwiz Link for Patient Letters

                        Word Version for Patient Letters



                        Fact Sheet



                        Fee Schedules



                        Save IPM Fund



                        If you have any questions, please feel free to contact Melinda Martin, [email protected], 270-554-9412, ext. 215 or Summer Moffitt, [email protected], 270-554-9412, ext. 204.



                        Thank you,





                        Hans C. Hansen, MD

                        President, ASIPP

                        Medical Director

                        The Pain Relief Centers, LLC

                        224 Commerce St

                        Conover, NC 28613

                        Phone: (828) 261-0467

                        Fax: (828) 261-7293

                        [email protected]


                        Laxmaiah Manchikanti, MD

                        Chairman of the Board and Chief Executive Officer, ASIPP

                        Medical Director, Pain Management Center of Paducah

                        Clinical Professor, Anesthesiology and Perioperative Medicine

                        University of Louisville, Kentucky

                        2831 Lone Oak Road

                        Paducah, KY 42003

                        Phone: 270-554-8373 ext. 101

                        Fax: 270-554-8987

                        [email protected]
                         
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