Insurance credentialing

[C Fiber]

For new and old pain docs out there,
Did you guys wait to get on most/all insurances before your started your practice? What if you are not approved to be a provider yet with some insurance companies? How would you bill for it?

Is it bad business to open your practice without being on most insurance companies? Would that piss off your referring docs?

Sorry for rambling, thanks for your advice in advance.

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[Pain_doc]

can take a few months or longer to get all the insurance credentialing/contracts done (plan on 6 months to be safe). If you're not a provider for the patient's insurance, the insurance company will either not pay you or pay you out of network benefits. The patients will be the ones who get really upset and then they will complain to the referring docs. Most insurance companies will not retroactively pay you (You can't sit on the bills until you're credentialed).

 

[C Fiber]

👎 That sucks. It only means that you have to be credentialed with every d*** insurance company in that region before you even open your door. Is there any way to speed up the process? Thank you so much for your help.

 

[Aether2000]

www.caqh.org

Apply early to their service....
Get an addy for mailing (doesn't have to be at the practice location) and request applications from each insurer early after the caqh is in force.
Apply to each insurer.
Start 6 months before the end of fellowship
If you are going into a partnership or group, have the group initially shunt to you the patients with plans in which you are credentialed.
We are in over 200 plans...

 

[Mister Mxyzptlk]

Trying to start up a solo practice in an area that already has other pain docs can be VERY difficult. I did it 10 years ago but it wasn't much fun and if I knew then what I know now I probably wouldn't have tried. I am not going to get into the referral pattern problems you'd have to deal with, and will confine my comments to the insurance piece.

In an area with a lot of pain docs the carriers might not even offer you a contract because they have enough people on the panel already. Some of them locked me out for several years. It took me about 6 years to get on United Healthcare.

At the opposite extreme, if you go where there are no pain docs you might want to go without contracts at first. Why? Let's say you go to Smalltown, USA. In response to your inquiry the carriers will send you contracts, you'll spend a bunch of money on a lawyer having them reviewed, and then when you go back to the carrier with proposed changes or a higher fee schedule they will tell you to take it or leave it. If there is no one else to go to in your area then the patients will still find you, and when the carrier doesn't pay your entire fee you are going to balance bill the patient. Explain to the patient that you have tried to get on their plan but the carrier is being obstinate. When the patients start complaining to the carriers then you can negotiate a better deal.

In some states like TX an HMO has to have a specialist within 75 miles. Find a place in the boonies and write your own ticket. Otherwise, you'd probably be better off joining a group and getting on their contracts, or perhaps working a deal with a hospital that can get you on them (with a first year income guarantee, office lease discount, etc). Bottom line: you drive better deals in underserved areas. The downside is they are underserved for a reason. Still, a small college town in the midwest has been very, very, good to one guy I know.

Some hospitals have affiliated IPAs that you can join. You qualify simply by virtue of being on the medical staff, and then you can be on all of those plans. That helped me quite a bit during startup since two hospitals here have those. You can (and should) opt out of the one that pays less if both IPAs offer a certain carrier contract. They will try to apply the lower rate if you are contracted through two different IPAs with two different fee schedules.

 

[drrinoo]

any thoughts on signing up for medicaid or Tx WComp as a strategy to generate a patient base and goodwill among referring physicians.

I did a small operational analysis of our academic practice....and it seemed for Texas Medicaid that axial spine injections covered their costs and generated a profit, albeit a small margin...the non-spinal procedures did not cover the costs (fixed and variable)...


and if the answer is no....(e.g., too high an overhead in a start-up despite availability/access)...is there room to accommodate these patients when the practice is mature and running at optimal efficiency?

also, as an aside....I checked the United Health Care website...they have this 'premium physician' database that is based on 'evidenced-based practice, appropriate utilization, and low complication/re-op rates'....it doesn't have categories for pain docs, but it does have categories for cancer, cardiac, and ortho/neurosurgery...

when you search the database for Texas ortho-spine, close to 200 practitioners are listed....but for NY and PA, there are less than 5 per state...and some states are not even listed (North Dakota, South Dakota)...understandably, Texas has one of the highest rates of spine surgery in the United States and a good tort climate, compared to NY/PA...but the numbers were incredibly disproportionate....

any thoughts

 

[Disciple]

Trying to start up a solo practice in an area that already has other pain docs can be VERY difficult. I did it 10 years ago but it wasn't much fun and if I knew then what I know now I probably wouldn't have tried. I am not going to get into the referral pattern problems you'd have to deal with, and will confine my comments to the insurance piece.

Would appreciate your (or others) input regarding the referral patterns. Personally, I would like to start my own practice next year, but will probably be consigned to an area with many pain docs.

Thanks.

 

[Mister Mxyzptlk]

Referral patterns can be hard to crack. If the relationships are grounded in mutual financial interests such as being partners in an ASC you can't break into that. The established pain docs will probably not welcome you and they will take a dim view of your trying to carve out a niche. You might not be able to find anyone who will agree to be your call coverage for medical staff privileges applications.

Two ways to meet new sources are (1) work part time doing gas and try to get the ortho/spine rooms and (2) visiting doctors' offices and talking to the doctor AND the staff. The office staff is very important. Some docs will just write "refer to pain management" and leave it to the office staff to fill in the blanks - a nice lunch for them works wonders. I send my staff around on the lunch circuit every 6-12 months. The other office staffs don't care how good you are, they mostly care about how easy your office makes their job. If it's very easy to send you patients and your staff is friendly guess what the other office staffs will do with those generic referrals?

One way that bypasses referrals is to advertise. I did this when I first started out in solo practice but I don't like the type of clientele one gets with that route.

Hang out in the doctors' dining room at lunch. Chat with people in the surgeons' lounge between cases. Go to medical staff meetings. Go to all the local medical society dinners. Serve on committees (no particular ones - look at who is on what committee and ask to be on the ones with potential referers e.g. neurologists, ortho, FP, etc). Keep your wallet full of business cards to hand out.

If you refer someone a patient there is a good chance you'll get one back. Look for opportunities to refer for EMGs, rotator cuff tears, carpal tunnel releases, etc. If someone asks for a good FP, reward one that has sent you patients.

Keep in mind the three A's of successful practice: able, affable, and available.

When I started up I did all of the things listed above. It is low yield compared to the time spent but one visit with a busy spine surgeon who takes a shine to you is all it takes to achieve lift-off.

Hope this helps.

 

[Disciple]

Thanks,

That's just what I was looking for.👍

Interesting what you said about serving on committees. I've been told the same by mentors I've had. Ditto for marketing to FP (early intervention, etc.)

 

[drrinoo]

Have any of you used another strategy, such as training community physicians (FPs/Int Med) in the performance of interventional techniques, as a way to improve patient access to pain treatments, improve your referring physicians bottom line, and finally, improve and solidify the quality of your referrals and referring relationships?

I realize this is very controversial...but on the surface it seems to be an incredibly effective and ethical physician marketing strategy? Mind you, you can stratify the complexity of procedures and decide what you are willing to teach?

After all, medicine is as grounded in physician education as it is in patient care,

 

[Disciple]

Interesting idea.

I would be willing to try this so long as the interventional training was accompanied by a crash course in diagnosis and conservative management of acute and sub-acute pain (pathophys/anatomy, physical exam, PT, bracing, membrane stabilizers, choosing imaging studies, etc.)

1-2 days of lecture followed by time with you in the procedure room. At the end of the course, hand them your business card?

 

[paz5559]

Have any of you used another strategy, such as training community physicians (FPs/Int Med) in the performance of interventional techniques, as a way to improve patient access to pain treatments, improve your referring physicians bottom line, and finally, improve and solidify the quality of your referrals and referring relationships?

I realize this is very controversial...but on the surface it seems to be an incredibly effective and ethical physician marketing strategy? Mind you, you can stratify the complexity of procedures and decide what you are willing to teach?

After all, medicine is as grounded in physician education as it is in patient care,

I wonder if teaching physicians and then setting them lose on the community subjects you to any vicarious liability when they say "well, that's the way Dr. Rinoo taught me to do it, your honor"

 

[Doctodd]

if you want WC, look for case manager conventions or seminars where they get CME's.

Agree with the other stuff.....get priviledges at hospitals and see patients that you arent on their plans.....UHC, CIgna, AEtna opened their panels quick for me since they had to pay me higher rates for inpatients. Before that, i was stonewalled with closed panels for >12 months.....coincidence that they opened their panels after i started seeing inpatients.

be persistent.....by law they cant have their panels closed all year.

T

 

[Aether2000]

I believe training those without sufficient backgrounds can be disastrous to patient safety, to interventional pain, and to the continuing development of the specialty. It denegrates pain medicine by effectively making the technical part of what we do the most prominent feature while subjugating the decision-making to a menial role.
There are family docs doing RF (poorly) now but they could care less about quality or results. It becomes all about money. A local family doc went to a couple of weekend warrior course, learned a few injections, and now plans on implanting spinal cord stimulators. The local pain community has notified the suppliers we will boycott in mass any company that supplies her with SCS leads or equipment.
There is an unscrupulous doctor in New Hampshire that is teaching CRNAs in his clinic to do vertebroplasty, pump and stim implants, and the CRNA has been doing these independently since 2003.
For the preservation of our profession as a profession, I don't think we should teach those without the appropriate background (anesth, pm&r, neurology and maybe interventional radiology) any techniques at all. This is a 180 degree directional change for me over the past few years, but I have seen the damage those with a little knowledge can do.

 

[C Fiber]

I have to agree with Algosdoc. I can say that my skills prior to fellowship was pathetic, although I did do a few RFs, etc. After a year of fellowship, I see that my patients are getting better. It really does not do the patients any justice to do a half-a@*# job. It's scary to think that CRNAs are doing vertebroplasties. How many do they do before they subject their patients to the procedure table? I can say after 10 vertebroplasties, I am still cautious about it. Ethically, do you tell your patients that your NURSE is gonna do the procedure for the 1st or 2nd time? Why did we work so hard to do medical school, residency, fellowship and pay a crap load for malpractice if I could have just gone to nursing school and do the same things?!

 

[Mister Mxyzptlk]

A local family doc went to a couple of weekend warrior course, learned a few injections, and now plans on implanting spinal cord stimulators. The local pain community has notified the suppliers we will boycott in mass any company that supplies her with SCS leads or equipment.

1. It's my understanding that the company MUST sell the equipment. I have been over this several times with Medtronic. They say they can't pick and choose who can buy or use their equipment. They used to have an approved implanter list but they scrapped it because of legal problems.

2. You have opened yourself to a potential lawsuit. Granted, the doc in question should not win based on medical logic. However, the law has its own internal logic system and I think you could get seriously hurt if that doc pursued litigation for restraint of trade (maybe slander and/or libel considerations if you gave the manufacturer your reasons either orally or in writing).

The only way to prevent this doctor from harming people is to make sure a hospital or ASC won't grant privileges. Unfortunately, in most states you can't stop a licensed doctor from doing whatever (legitimate) therapy they please in their office. She could probably put a procedure room in the office and start maiming people until either the lawyers or the board put a stop to it. Unfortunately, both processes require multiple patient injuries before they kick in.

I have reported two neurologists to the board for doing "CESI's" in the office using a blind technique with 25g spinal needles. The op reports are boilerplate that describe needle insertion with the grammatically and medically interesting sentence "The epidural space was searched and entered". The board told me they can't do anything.

One guy injected 1 cc of Kenalog and 1 cc of 1% lidocaine. Within minutes the patient complained of weakness in all four extremities. He ran out of the room and returned with . . . . . . . a consent form for her to sign. Then he just sent her home, weak-kneed and numb. I got to do her cervical blood patch. The patient tried to sue him but no one would take the case because she hadn't suffered a bad enough injury. "Better to be lucky than good."

 

[medicineman1]

I want an opinion from you seasoned guys-
firstly, I'm curious are you gas trained or PM&R trained? What (honestly) is your opinion re: the best springboard for success and comfort to be a really good interventional pain doc?

Are you guys happy? Would you do anything different? Would you do another field?

I am currently doing anesthesia and find the hours in the OR to drag, Im considering changing to PMR but it will cost me time, at least one year, maybe two?

I do realize that this is another very political topic- but I want your honest opinions?

 

[Aether2000]

Companies have and do restrict the sale of equipment to those who are trained to use it. If they did not, then we would run into the situation where a CRNA went to a Medtronics programming course. They were given a certificate for the course that they then promptly presented to their hospital claiming to be certified to implant stimulators. This actually happened.
I agree with you physicians are not good at policing themselves until it becomes politically expedient to do so.
There must be some basal level of training required for procedures and certainly for advanced procedures. Perhaps we need a stratification based on education and trainng....

 

[Disciple]

I've been doing short educational training sessions with our Medtronics rep on implantable devices, and was told that verification of this training is required to purchase any of their implantable devices at the present time or in the future.

 

[Doctodd]

I want an opinion from you seasoned guys-
firstly, I'm curious are you gas trained or PM&R trained? What (honestly) is your opinion re: the best springboard for success and comfort to be a really good interventional pain doc?

Are you guys happy? Would you do anything different? Would you do another field?

I am currently doing anesthesia and find the hours in the OR to drag, Im considering changing to PMR but it will cost me time, at least one year, maybe two?

I do realize that this is another very political topic- but I want your honest opinions?

Id stay and finish Anesthesia and do a pain fellowship.....you will most likely suffer no matter what kind of residency you are in.

T

 

[paz5559]

There must be some basal level of training required for procedures and certainly for advanced procedures. Perhaps we need a stratification based on education and trainng....

So when ISIS teaches a cervical course, and includes cervical transforaminal access (as they characterize it in their Phase 3 training), the certificate of completion of that weekend course gives the participant ISIS's sanction and approval that they are competent to perform such procedures?

Makes me wonder if ISIS might be on the hook in case that same doc goes out and has a catastrophic complication.

 

[Aether2000]

ISIS does not certify anyone for anything...
They do offer a "certificate of completion" that effectively states they attended the course and received credit hours for attending.
I think we all share the concerns about having minimally trained individuals practicing interventional pain, whether they be family practice docs (that CAN be certified by the ABIPP/ASIPP board, WIP, and the ABPMedicine) or anesthesiologists out of residency for 10 years that have never used a fluoroscope before....

 

[paz5559]

ISIS does not certify anyone for anything...
They do offer a "certificate of completion" that effectively states they attended the course and received credit hours for attending.
I think we all share the concerns about having minimally trained individuals practicing interventional pain, whether they be family practice docs (that CAN be certified by the ABIPP/ASIPP board, WIP, and the ABPMedicine) or anesthesiologists out of residency for 10 years that have never used a fluoroscope before....

Boy, talk about a splitting of hairs ... and you really believe that training and competence aren't implicit in the notion of "completion"? The lawyers may buy that, but I am not certain you would get a jury to.

ISIS certainly gives the impression it prepares practitioners to perform procedures after taking their training courses (labeled as "instructional and educational vehicles" with the caveat that, "It does NOT replace the time, proctoring, and professionalism it takes to learn these procedures.")

Seems like an awfully find distinction to draw, especially at $1800/course.

 

[Kwijibo]

Enough of the cheap shots on anesthesia.
The reality of the matter is that it is not the anesthesiologist who are picking up the needle and hurting people, (And you know what, if they get a high spinal, at least they can deal with the complications) it is the PMand R guys who have busy PT practices who are learning this stuff at weekend courses, the family practice guys, the neurologists, the radiologists, the surgeons, the nurses, and whoever else feels like doing injections. The bottom line is that it is the ones without proper training.

 

[drusso]

Enough of the cheap shots on anesthesia.
The reality of the matter is that it is not the anesthesiologist who are picking up the needle and hurting people, (And you know what, if they get a high spinal, at least they can deal with the complications) it is the PMand R guys who have busy PT practices who are learning this stuff at weekend courses, the family practice guys, the neurologists, the radiologists, the surgeons, the nurses, and whoever else feels like doing injections. The bottom line is that it is the ones without proper training.

Kwijibo,

It seems like you're at the forefront a very important issue in our field: Parameters of quality assurance in pain medicine. If you could please pass along the references informing your opinions about primary specialty scope of practice and rates of complications versus outcomes in interventional pain medicine that would be most helpful.

With P4P (pay for performance) coming at us like an 18-wheeler without breaks the field needs to have clearly defined metrics for quality and outcomes and well-delineated standards for competence.

Please post the sources you have so we can all benefit from a critical review of the information.

 

[Kwijibo]

gtive me a break, I'm talking purely anecdotal!
The bottom line is that anyone can pick up a needle and start injecting people and it is sad.That is what I was getting at.
My comment was more a stand for anesthesiologists who take a beating on this PM+R driven site. I have no problem with any specialist doing pain as long as there is sufficient training. As a matter of fact I watched with this super busy pain doc perform procedures in this surgi center and I was appauled! AP medial branch blocks with placement on the transverse process. then cervical RFA with the patient asleep and the endpoint somewhere on the lamina(nowhere near the MB).
He asked me if I ever saw it done this way and I said 'no' then he proceeded to tell me Sunil Panchal taught him that technique.
But whatever,
Our field needs regulation of some sort. People talk about making a pain residency, what a joke! Docs dont even need training to do this stuff, why would anyone waste 3 years and have no job because someone with no training and who already has control of the patients is making all the $$?
Algos, you sound like a bitter ex-girlfriend when it comes to anesthesia. what happened along the way???

 

[drusso]

gtive me a break, I'm talking purely anecdotal!
The bottom line is that anyone can pick up a needle and start injecting people and it is sad.That is what I was getting at.
My comment was more a stand for anesthesiologists who take a beating on this PM+R driven site. I have no problem with any specialist doing pain as long as there is sufficient training. As a matter of fact I watched with this super busy pain doc perform procedures in this surgi center and I was appauled! AP medial branch blocks with placement on the transverse process. then cervical RFA with the patient asleep and the endpoint somewhere on the lamina(nowhere near the MB).
He asked me if I ever saw it done this way and I said 'no' then he proceeded to tell me Sunil Panchal taught him that technique.
But whatever,
Our field needs regulation of some sort. People talk about making a pain residency, what a joke! Docs dont even need training to do this stuff, why would anyone waste 3 years and have no job because someone with no training and who already has control of the patients is making all the $$?
Algos, you sound like a bitter ex-girlfriend when it comes to anesthesia. what happened along the way???

Oh, I see. It's *NOT* about specialty of origin issues after all. It's more about individual factors, knowing one's technical limits, medical knowledge, and competence. That makes more sense to me.

 

[chinochulo]

As a matter of fact I watched with this super busy pain doc perform procedures in this surgi center and I was appauled! AP medial branch blocks with placement on the transverse process. then cervical RFA with the patient asleep and the endpoint somewhere on the lamina(nowhere near the MB).
He asked me if I ever saw it done this way and I said 'no' then he proceeded to tell me Sunil Panchal taught him that technique.

Kwijibo, don't forget about our enterprising pain doc who performs LESI plus intra-articular facet injections on the same patient during one visit? Oh wait, he is fellowship-trained.

 

[jsaul]

gtive me a break, I'm talking purely anecdotal!
The bottom line is that anyone can pick up a needle and start injecting people and it is sad.That is what I was getting at.
My comment was more a stand for anesthesiologists who take a beating on this PM+R driven site. I have no problem with any specialist doing pain as long as there is sufficient training. As a matter of fact I watched with this super busy pain doc perform procedures in this surgi center and I was appauled! AP medial branch blocks with placement on the transverse process. then cervical RFA with the patient asleep and the endpoint somewhere on the lamina(nowhere near the MB).
He asked me if I ever saw it done this way and I said 'no' then he proceeded to tell me Sunil Panchal taught him that technique.
But whatever,
Our field needs regulation of some sort. People talk about making a pain residency, what a joke! Docs dont even need training to do this stuff, why would anyone waste 3 years and have no job because someone with no training and who already has control of the patients is making all the $$?
Algos, you sound like a bitter ex-girlfriend when it comes to anesthesia. what happened along the way???

dude chill out-- no one is taking shots at anesthesiology on this site... when in doubt-- read gordon iriving's famous treatise "I am an anesthesiologist" or smoke some endo and drink some gin and juice...which ever but relax

 

[Doctodd]

sounds like Kwijbo had a bad day.....i didnt know this site was PM&R driven?

I think we should all stop generalizing....there are plenty of Anesthesia pain docs who suck, and there are plenty of PM&R docs who are very extremely competent.

Of course i think everyone should get along and redirect all this time snapping at each other to do research, or write their congressman about the reductions for us cuz we dont have the lobbysists that the hospitals have, or allow us to open medspas just because it isnt on somebody's political agenda but unfortunatley because it may be a necessity someday.

But most importantly, this is all off-topic to the original post.

T

 

[Spine Specialist]

I think we should all stop generalizing....there are plenty of Anesthesia pain docs who suck, and there are plenty of PM&R docs who are very extremely competent.

Of course i think everyone should get along and redirect all this time snapping at each other to do research, or write their congressman about the reductions for us cuz we dont have the lobbysists that the hospitals have, or allow us to open medspas just because it isnt on somebody's political agenda but unfortunatley because it may be a necessity someday.

But most importantly, this is all off-topic to the original post.

T

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