Medicare going to decrease payments in 2.5 efficiency penalty on most specialists

[mille125]

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Have you guys looked at this?

Its a zero sum game. Reward primary care and punish specialists. You better believe that interventional pain mgmt will be on the menu.

 

[clubdeac]

Have you guys looked at this?

Its a zero sum game. Reward primary care and punish specialists. You better believe that interventional pain mgmt will be on the menu.

I saw that…very disheartening. Got to get a back up plan. FIRE

 

[mille125]

I saw that…very disheartening. Got to get a back up plan. FIRE

Dr Oz spearheading, I think.

 

[mdo1738]

Also the ASM program in 2027 looks like yet another attack against us. Death by a million paper cuts.

 

[clubdeac]

Also the ASM model in 2027 looks like yet another attack against us. Death by a million paper cuts.

What’s that exactly

 

[mdo1738]

What’s that exactly

ASM (Ambulatory Specialty Model) | CMS

ASM (Ambulatory Specialty Model)

www.cms.gov

Sounds like something that will increase our workload/administrative burden without any benefit to the patient while also probably financially penalizing physicians who provide “avoidable, unnecessary care” (which I have a strong suspicion they will determine the extremely vague “unnecessary care” to be “literally any interventional pain procedure”).

 

[clubdeac]

Well that sounds terrible.

 

[RoloTomassi]

The efficiency adjustment is such BS. We've had to get faster to keep our heads above the rising water level, just to get smacked with this penalty. And it repeats every 3 years, on the assumption that there is no end to how fast you can do a procedure. Glad I just opted out of MC.

 

[SSdoc33]

awful policy for us.

Oz has always hated what we do.

as drusso would say, elections have consequences.....

dr. oz epidurals - Google Search

 

[hyperalgesia]

Many specialties are impacted by this. Now that Medicare and the insurance industry have a monopoly on healthcare, why wouldn't they use their leverage to lower fees to rock bottom?

The long term consequences of socialism are utterly predictable.

 

[nvrsumr]

bad for us but we may have more e&m visits than some other procedural specialities

I have really increased the number of follow up visits due to ins regs, telehealth and declining procedure reimbursement versus 10 years ago

 

[SSdoc33]

bad for us but we may have more e&m visits than some other procedural specialities

I have really increased the number of follow up visits due to ins regs, telehealth and declining procedure reimbursement versus 10 years ago

f/u visits for mbbs and post RFs are crucial. easy and quick. even f/u for ESIs in LOLs with stenosis. agree that i didnt have to do this as much in the past

 

[painstop]

Medicare Will Require Prior Approval for Certain Procedures

A pilot program in six states will use a tactic employed by private insurers that has been heavily criticized for delaying and denying medical care.

www.nytimes.com

You guys should read the NYT article about the AI algorithm for straight Medicare that will go into effect to deny coverage for the following conditions in six states (People enrolled in traditional Medicare who live in Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington State will be included in the experiment, which is expected to start in January and last for six years):

Here's a full list of the procedures that will be included in the pilot program: Electrical Nerve Stimulators Sacral Nerve Stimulation for Urinary Incontinence Phrenic Nerve Stimulator Deep Brain Stimulation for Essential Tremor and Parkinson's Disease Vagus Nerve Stimulation Induced Lesions of Nerve Tracts Epidural Steroid Injections for Pain Management excluding facet joint injections Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) Cervical Fusion Arthroscopic Lavage and Arthroscopic Debridement for the Osteoarthritic Knee Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea Incontinence Control Devices Diagnosis and Treatment of Impotence Percutaneous Image-Guided Lumbar Decompression for Spinal Stenosis Skin and Tissue Substitutes —only applicable to MAC jurisdictions and states that have an active LCD in place

 

[clubdeac]

Hold up, so all epidurals are on the chopping block?

 

[Dr. Ice]

We have already been making our straight Medicare patients do weeks of pointless PT for their injection cause we saw that this was
coming. I have already been telling all my Medicare patients that they won’t be able to get their injection how they used to starting in January. A lot of them are planning to move to Florida lol

 

[BobBarker]

Bad deal. Maybe have to do more telemeds for my rural people and then come to the office for the injection once approved.

 

[mdo1738]

This will increase office administrative burden, cause real harm to patients, and probably not save CMS any money. What a great idea.

 

[nvrsumr]

Trying to figure out if I can retire in 6 years.. nope

 

[DoYouEvenLiftBro]

We have already been making our straight Medicare patients do weeks of pointless PT for their injection cause we saw that this was
coming. I have already been telling all my Medicare patients that they won’t be able to get their injection how they used to starting in January. A lot of them are planning to move to Florida lol

Happy to take them! Tell them to move to port charlotte Venice Sarasota lol

 

[Status Sciaticus]

i usually say they cant tolerate PT due to pain, usually bypasses this issue, or that they have been doing a physician directed home exercise program which many are doing.

 

[clubdeac]

i usually say they cant tolerate PT due to pain, usually bypasses this issue, or that they have been doing a physician directed home exercise program which many are doing.

I do that too, and then still get the denial and have to do a P2P. When I call them, they say they didn’t get any of the notes. It’s such a joke and a waste of every everyone’s time.

 

[mdo1738]

I do that too, and then still get the denial and have to do a P2P. When I call them, they say they didn’t get any of the notes. It’s such a joke and a waste of every everyone’s time.

They are always finding incredible new ways to waste all of our time. Had an SI joint injection get denied today because “your doctor’s notes did not state that the shot planned by your doctor is the same as the one requested” nor did it “say that your doctor will not be performing other injections at the same time”. Just incredible levels of pointless stupidity.

 

[Dr. Ice]

Our people don’t even submit now until there is proof of LCD compliance because they don’t “want to have to do more work” on their end. Can’t do a peer to peer if theres nothing to deny because it wasn’t even submitted.

All good, I’m happy to be a highly paid PT orderer with an evergreen contract

 

[PinchandBurn]

I think its best to be out of network for mcr and all insurances eventually. Keep your NP/pa in network


Lots of naysers....but its the only way to be compensated commiserate with what we do.

 

[Ducttape]

just to be clear - this is specifically stating that in those states we will need to get prior auth. did not say that they were denied. just like we get prior auth for private insurance.


i do PA for all procedures. make sure your smartphrases encapsulate all the requirements. i find it easiest to "copy" the LCD as the main part of the smartphrase.


the most recent one - the PA for MBB needs to say "to determine if radiofrequency ablation is a possible treatment."

 

[Status Sciaticus]

I do that too, and then still get the denial and have to do a P2P. When I call them, they say they didn’t get any of the notes. It’s such a joke and a waste of every everyone’s time.

I usually will try to get a visit out of it by having a telemedicine visit during the P2P call. Reason for visit is to discuss denial and discuss procedural planning. Pays out at 99213 without issue. Can even do 99214 if you can justify that it is pre-procedure planning.

They are always finding incredible new ways to waste all of our time. Had an SI joint injection get denied today because “your doctor’s notes did not state that the shot planned by your doctor is the same as the one requested” nor did it “say that your doctor will not be performing other injections at the same time”. Just incredible levels of pointless stupidity.

Yikes. Better add these to my LCD macros.

I think its best to be out of network for mcr and all insurances eventually. Keep your NP/pa in network


Lots of naysers....but its the only way to be compensated commiserate with what we do.

Dont you have to arbitrate each MCR with the insurance companies? or is that just for UCR?

 

[clubdeac]

I usually will try to get a visit out of it by having a telemedicine visit during the P2P call. Reason for visit is to discuss denial and discuss procedural planning. Pays out at 99213 without issue. Can even do 99214 if you can justify that it is pre-procedure planning.



Yikes. Better add these to my LCD macros.



Dont you have to arbitrate each MCR with the insurance companies? or is that just for UCR?

I’ve started scheduling visits at the same time as the P2P so we can all be in the phone together 😉

Last week however once the reviewer heard I had the patient in the room she said she would not continue and said we needed to reschedule. It was insane. I had to have the patient step out while I finished the p2p

 

[SSdoc33]

i wouldnt say i outright lie, but i come pretty close to it to get things approved if i think they will help the patient. at this point, IDGAF what the insurers say about what get covered, for whom, and when.

im not making gramma who can barely walk go to 2 months of PT. im not denying a patient an RF b/c their pain is a 5 and not a 6.

 

[Dr. Ice]

The challenge is when your precert won’t even submit unless the LCD is met. To deal with the denial after submission is one thing, to deal with getting blocked by your own people is another lol..but what do I know.

This health system I’m at is highly profitable and I can guarantee they don’t have a lot of unpaid money sitting in AR that won’t be collected. The last two private groups I was at were somewhere between 19-25 mill in AR/year probably because of this nonsense

 

[clubdeac]

So back to original post. Does anyone have any idea how much pain procedures will be slashed in 2026? They’re going to base it on how efficiently we can perform them?

That’s really sad bc A) some of us are very efficient because we worked very hard to become extremely skilled at these procedures and B), some are very efficient because they’re just sloppy and lazy.

So those of us that have worked hard to do what we do well, will be penalized because of that and because of our sloppy and lazy colleagues. Just wondering how painful it’s gonna be and how much I need to save this year to stay on track.

 

[Ducttape]

FWIW, primary care for what they do is woefully underpaid. Those who do that or office visits are underpaid.

CMS should be boosting their pay without affecting procedures but if they feel there is only limited funds....

 

[DOctorJay]

FWIW, primary care for what they do is woefully underpaid. Those who do that or office visits are underpaid.

CMS should be boosting their pay without affecting procedures but if they feel there is only limited funds....

how can there be limited funds for physician fees but not facility fees?

 

[Ducttape]

ask why healthcare was cut in the last bill.....

 

[Status Sciaticus]

The challenge is when your precert won’t even submit unless the LCD is met. To deal with the denial after submission is one thing, to deal with getting blocked by your own people is another lol..but what do I know.

This health system I’m at is highly profitable and I can guarantee they don’t have a lot of unpaid money sitting in AR that won’t be collected. The last two private groups I was at were somewhere between 19-25 mill in AR/year probably because of this nonsense

Maybe the reason that your health system is highly profitable is because of how they do what they do and dont let non-LCD met procedures happen that can get clawed back later.

ask why healthcare was cut in the last bill.....

elections have consequences.

 

[Dr. Ice]

Maybe the reason that your health system is highly profitable is because of how they do what they do and dont let non-LCD met procedures happen that can get clawed back later.



elections have consequences.

I’m sure that’s exactly why..doesn’t make the lives of doctors any easier though when the patients are complaining about their limbs falling off because of pain, but I get it. Like I said, I’ll order PT all day long on these people..very low risk

 

[jsaul]

I’m sure that’s exactly why..doesn’t make the lives of doctors any easier though when the patients are complaining about their limbs falling off because of pain, but I get it. Like I said, I’ll order PT all day long on these people..very low risk

How much you getting paid for ordering PT all day?

 

[Dr. Ice]

How much you getting paid for ordering PT all day?

More than I should