How would a cash-based clinic change your practice?

[Ferrismonk]

Hello everyone. I was thinking today while reviewing insurance denials and limitations of care how much the insurance system is controlling how we practice. Even if not directly by authorizations and denials, they even control us by how our notes are designed, what type of EMR we use, the fact we even use an EMR, and the multitude of other policies we must enforce if we accept Medicare, etc.

My question is this: what would you do different if you were 100% cash-based?

Would you even do MBB before RF? Would you do MBB then burn if they got relief while on the table? Would you just do intraarticular facets? How many facet levels would you try to do at once? Would you do multiple regions such as C-spine, L-spine, SI joints at once? Would you do ESI the same day as a facet procedure? Would you do a bunch of stuff we don't do anymore such as epidurolysis, IDET, etc? Would you even use steroids and instead just use prolo, PRP, pitcher plant extract, whatever? Would you target surrounding structures with prolo/PRP when doing a joint injection to help stabilize the joint as well?

How would you change your practice?

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[SSdoc33]

Hello everyone. I was thinking today while reviewing insurance denials and limitations of care how much the insurance system is controlling how we practice. Even if not directly by authorizations and denials, they even control us by how our notes are designed, what type of EMR we use, the fact we even use an EMR, and the multitude of other policies we must enforce if we accept Medicare, etc.

My question is this: what would you do different if you were 100% cash-based?

Would you even do MBB before RF? Would you do MBB then burn if they got relief while on the table? Would you just do intraarticular facets? How many facet levels would you try to do at once? Would you do multiple regions such as C-spine, L-spine, SI joints at once? Would you do ESI the same day as a facet procedure? Would you do a bunch of stuff we don't do anymore such as epidurolysis, IDET, etc? Would you even use steroids and instead just use prolo, PRP, pitcher plant extract, whatever? Would you target surrounding structures with prolo/PRP when doing a joint injection to help stabilize the joint as well?

How would you change your practice?

definitely no mbbs. straight to RF. most likely more regenerative medicine. less PT prior to injections that i think are needed, rather than having the patient wait 6 weeks and do all the copays with therapy. i'd remove some of the fluff from the notes.

however, even if I were 100% cash pay, you still have to document ad nauseum for medicolegal reasons. also, by doing much of he above you may be outside the "standard of care", whatever that is, which could open you up to some legal liability

 

[drusso]

I've been offering cash services for over a decade---everything under sun. Some people just have no other means to get what they need except to open their wallets.

It's a refreshing way to work with patients.

 

[Ferrismonk]

I've been offering cash services for over a decade---everything under sun. Some people just have no other means to get what they need except to open their wallets.

It's a refreshing way to work with patients.

I understand, but do you do things differently when it's cash? Do you still do 2x MBBs two weeks apart, an OV, then a bilateral 2-level RFA?

 

[geauxg8rs]

I understand, but do you do things differently when it's cash? Do you still do 2x MBBs two weeks apart, an OV, then a bilateral 2-level RFA?

For cash I will do the RFA if it is a repeat without any mbbs. If new then mbb x1 then rf

 

[Multimodal]

I think it'd be nice to charge the insurance for 1 MBB to confirm levels, then an RFA for cash. saves ins and patient time and money. not sure about how appropriate.....

 

[DODOCSS]

For cash I will do the RFA if it is a repeat without any mbbs. If new then mbb x1 then rf

w/ insurance, why would you repeat MBB if prior RF was successful?

 

[Nodolor]

w/ insurance, why would you repeat MBB if prior RF was successful?

Did you read his post Einstein?

"For cash I will do the RFA if it is a repeat without any mbbs. If new then mbb x1 then rf"

 

[DODOCSS]

Did you read his post Einstein?

"For cash I will do the RFA if it is a repeat without any mbbs. If new then mbb x1 then rf"

Yes, kamala I read it. Your comprehension is the problem.

 

[Dr. Ice]

I think it really depends on your market. If there is a doc that does what you do within every 2 miles or so, cash options are not great. Cause someone will offer something covered by insurance whether or not it will work and the ultimate reality is the patient will get so frustrated that they will get cut or pay cash for Mary Jane or get a stimulator placed in them that shouldn’t have gone to perm at all..honestly my biggest issue in my territory is stim ******. They are the most horrendous human beings. Will just stim everything , all the new toys. Then the patients come back to me and I’m like well... 🤷🏽‍♂️

 

[geauxg8rs]

Did you read his post Einstein?

"For cash I will do the RFA if it is a repeat without any mbbs. If new then mbb x1 then rf"

Sometimes insurers have required to repeat mbbs if the last rf was say >2 years ago, or if I can’t find the prior physicians notes.

 

[drusso]

I understand, but do you do things differently when it's cash? Do you still do 2x MBBs two weeks apart, an OV, then a bilateral 2-level RFA?

When patients are paying cash, they are paying for my best medical judgment not for me to check the boxes for a third-party payer.

 

[Ducttape]

w/ insurance, why would you repeat MBB if prior RF was successful?

because insurance requires.

most local carriers request 2 "clinically meaningful" procedures prior to a subsequent RFA, while one can be the previous RFA. so gotta mix in a
"differential" MBB that specifically states that "the purpose of the injection is to determine if RFA is appropriate".

 

[nvrsumr]

When paid cash I do procedure and office visit on same day(biggest benefit to patient). Never do dx blocks before RFA. Will inject different areas or bilaterally on same day. Patients sometimes submit a claim to their insurance after a cash procedure then request a refund if insurance pays so I have them sign an ABN as well

 

[bedrock]

Hello everyone. I was thinking today while reviewing insurance denials and limitations of care how much the insurance system is controlling how we practice. Even if not directly by authorizations and denials, they even control us by how our notes are designed, what type of EMR we use, the fact we even use an EMR, and the multitude of other policies we must enforce if we accept Medicare, etc.

My question is this: what would you do different if you were 100% cash-based?

Would you even do MBB before RF? Would you do MBB then burn if they got relief while on the table? Would you just do intraarticular facets? How many facet levels would you try to do at once? Would you do multiple regions such as C-spine, L-spine, SI joints at once? Would you do ESI the same day as a facet procedure? Would you do a bunch of stuff we don't do anymore such as epidurolysis, IDET, etc? Would you even use steroids and instead just use prolo, PRP, pitcher plant extract, whatever? Would you target surrounding structures with prolo/PRP when doing a joint injection to help stabilize the joint as well?

How would you change your practice?

I wouldn't do MBB before RFA in medicare patients with extension based pain but no significant stenosis, but I would on 55 yr olds with only mild-moderate facet changes and a more equivocal exam.

I would definitely do IA facets (as I still do) on young patients and patients s/p trauma/MVA, instead of going straight to RFA.

You can only inject some much steroid at once, so I wouldn't do cervical and lumbar on same day.

I wouldn't do IDET etc, because it doesn't work.

I would go straight to PRP instead of steroid for all peripheral joint/ligament issues.

 

[drpainfree]

I've been offering cash services for over a decade---everything under sun. Some people just have no other means to get what they need except to open their wallets.

It's a refreshing way to work with patients.

offering cash services is different from running a cash-only practice. I assume you still accept insurance. Otherwise, please enlighten us how to make the transition. I'm sick and tired of dealing insurance.

 

[painfree23]

What do you for the patient who can’t afford PT copays but is clearly hurting from a radic and needs an injection? Insurance will likely give issues regarding lack PT failure right? I usually document some HEP as an option.

 

[paindoctor2014]

Sometimes insurers have required to repeat mbbs if the last rf was say >2 years ago, or if I can’t find the prior physicians notes.

Correct. Which is crazy bc if the rfa is working that well for the patient why go through all the steps again? Punishment for effective treatment

 

[buddababa]

Correct. Which is crazy bc if the rfa is working that well for the patient why go through all the steps again? Punishment for effective treatment

Just had this happen again - now patient is mad at me. I give up.