insurance shenanigans

[kstarm]

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So the last two were a little beyond what I typically see. Have a patient with classic occipital neuralgia. I place order for occipital nerve block. Insurance comes back denying it stating the diagnosis isn't covered. So I can do an occipital nerve block for something other than occipital neuralgia??

Lady on belbucca outpatient for chronic pain complaints, this is not a palliative patient, send refill. Insurance states she needs to try alternative first. The only alternative they accept is IV morphine. IV morphine outpatient ??

I wonder why they just don't refuse to cover stuff instead of all the hoops, and then I started wondering if they make more money by having the clinics tied up with prior auths and denials and thus not being able to scale up as easily. Just venting...

 

[callmeanesthesia]

So the last two were a little beyond what I typically see. Have a patient with classic occipital neuralgia. I place order for occipital nerve block. Insurance comes back denying it stating the diagnosis isn't covered. So I can do an occipital nerve block for something other than occipital neuralgia??

Lady on belbucca outpatient for chronic pain complaints, this is not a palliative patient, send refill. Insurance states she needs to try alternative first. The only alternative they accept is IV morphine. IV morphine outpatient ??

I wonder why they just don't refuse to cover stuff instead of all the hoops, and then I started wondering if they make more money by having the clinics tied up with prior auths and denials and thus not being able to scale up as easily. Just venting...

Morphine makes her nauseated and itchy, therefore contraindicated. Right? If they can play stupid games then so can we.

 

[Ducttape]

better yet:

"The patient was unable to complete the certification for placing her own IV for home IV morphine use."

 

[PMROralBoards]

Just bill trigger points with steroid to the back of the patients head

 

[kstarm]

Morphine makes her nauseated and itchy, therefore contraindicated. Right? If they can play stupid games then so can we.

Oh right I play stupid games every day with them, I just couldn't believe someone would actually encourage IV opioid use outside of a hospice/inpatient setting, I mean what could go wrong...

 

[cowboydoc]

Oh right I play stupid games every day with them, I just couldn't believe someone would actually encourage IV opioid use outside of a hospice/inpatient setting, I mean what could go wrong...

Had a policy demand failure of fentanyl, among other opioids, before auth of bupe. Medically reasonable isn't a strong consideration with many of these policies.

 

[powermd]

I charge cash for all my peripheral nerve blocks now. $350 for a full set of posterior head blocks (occipitals + auriculars). Not playing the trigger point game for $50 anymore. My time, skill, and results are worth way more than that.

 

[pmrmd]

How many people in a year are willing to pay that much for that little?

 

[callmeanesthesia]

I charge cash for all my peripheral nerve blocks now. $350 for a full set of posterior head blocks (occipitals + auriculars). Not playing the trigger point game for $50 anymore. My time, skill, and results are worth way more than that.

Are you doing that under ultrasound? I usually just call it a TPI if it’s an insurance that won’t pay for occipital. Barring that I’d probably just bill a 99214.

 

[powermd]

Are you doing that under ultrasound? I usually just call it a TPI if it’s an insurance that won’t pay for occipital. Barring that I’d probably just bill a 99214.

Yes, I don't do any blind injections.

No commercial ins pays me for 76942 now, well- Harvard Pilgrim, but no others. Most have specific policy guidelines that say no occipitals or peripheral nerve blocks. So, I'm not going to lie and call it a TP just so I can get paid chump change.

99214 pays me like $100. I'll bill the 99214 if we have sufficient discussion to support it, then charge cash for the blocks.

How many people in a year are willing to pay that much for that little?

Everyone so far. I get great results with it. Patients return for repeats every 3-6 mos, or just to top up one area whereas the others continue to do well.

 

[PMROralBoards]

Yes, I don't do any blind injections.

No commercial ins pays me for 76942 now, well- Harvard Pilgrim, but no others. Most have specific policy guidelines that say no occipitals or peripheral nerve blocks. So, I'm not going to lie and call it a TP just so I can get paid chump change.

99214 pays me like $100. I'll bill the 99214 if we have sufficient discussion to support it, then charge cash for the blocks.



Everyone so far. I get great results with it. Patients return for repeats every 3-6 mos, or just to top up one area whereas the others continue to do well.

Is there anything special or different that you are doing with the occipital blocks? I’ve never seen a patient get more than one month relief and generally use it as a bridge for Botox in the second month to get them through to the repeat Botox injection.

 

[buddababa]

Is there anything special or different that you are doing with the occipital blocks? I’ve never seen a patient get more than one month relief and generally use it as a bridge for Botox in the second month to get them through to the repeat Botox injection.

my occipital blocks usually last minimum 3-6 months, perhaps your technique may need refining, i use bupi and depo

 

[powermd]

Is there anything special or different that you are doing with the occipital blocks? I’ve never seen a patient get more than one month relief and generally use it as a bridge for Botox in the second month to get them through to the repeat Botox injection.

Pure hydrodissection- no steroid. Just bupi 0.125%, 5-10 mL per zone. Typically I will do the base of the traps superficially, then deep to the traps around C2, then if there seems to be auricular involvement, the SCM both superficially and deep along the posterior border. Sometimes the superficial traps at the base of the skull if it's all occipital. Total injectate about 20 mL per side.

 

[PMROralBoards]

my occipital blocks usually last minimum 3-6 months, perhaps your technique may need refining, i use bupi and depo

I typically go in at the occipital protuberance, go 1/3 of the way to the mastoid process and inject 2cc, go another 1/3 in and inject 1cc. Then I pull back to the initial insertion and redirect to the contra lateral side and repeat. I do 40 of depo with 5cc lido 1%. Can you clarify your approach?

 

[bedrock]

my occipital blocks usually last minimum 3-6 months, perhaps your technique may need refining, i use bupi and depo

My occipital blocks last 4 months on average. Also bup and depo.

Still getting paid on occipital blocks by everyone except Cigna.

 

[powermd]

Saw a patient today who I treated with multiple cranial peripheral nerve blocks 3 weeks ago. Had a history of severe migraine starting at age 13. The pain is mainly a pressure sensation like a bowl over the vertex of the skull. Headaches are almost every day and can go on for weeks. Long list of meds and treatments tried,. Pretty much no stone unturned. Patient is early 20s and in pharmacy school. Some improvement with periodic botox. Since my injections patient has been headache-free from the time I did the procedure, which is the longest they've ever gone without headache. Preventive medications still on board, but has taken no abortives. I did my usual occipitals, great auriculars, supraorbital/trochlear, and zygomaticofacial. Total volume was 40 mL. This was a great way to start the weekend, I'm so happy for this person.

 

[lobelsteve]

Saw a patient today who I treated with multiple cranial peripheral nerve blocks 3 weeks ago. Had a history of severe migraine starting at age 13. The pain is mainly a pressure sensation like a bowl over the vertex of the skull. Headaches are almost every day and can go on for weeks. Long list of meds and treatments tried,. Pretty much no stone unturned. Patient is early 20s and in pharmacy school. Some improvement with periodic botox. Since my injections patient has been headache-free from the time I did the procedure, which is the longest they've ever gone without headache. Preventive medications still on board, but has taken no abortives. I did my usual occipitals, great auriculars, supraorbital/trochlear, and zygomaticofacial. Total volume was 40 mL. This was a great way to start the weekend, I'm so happy for this person.

40cc in head and neck? Id be too scared. LAST or vascular uptake.

 

[BobBarker]

I also have a late 20s lady that I inject supraorbital/supratroclear and across the temples. Every 6 weeks for about 3 years.

 

[powermd]

40cc in head and neck? Id be too scared. LAST or vascular uptake.

I use very dilute local, 0.125% bupi. It works fine- you don't need 0.25% to do the job with soft tissue procedures. I've been diluting down my local for years.

 

[lobelsteve]

I use very dilute local, 0.125% bupi. It works fine- you don't need 0.25% to do the job with soft tissue procedures. I've been diluting down my local for years.

All good. My only suggestion would be to have a breakout box, consider intralipid availability, and have all staff review Rosenthal quarterly.

Be prepared and it will never happen.