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So you get your >30% of cases in ASC to meet AKS by having a day of, what sounds like mostly B&B, in the ASC? Is that what youre saying?
Pain in Ortho Group- Partnership?
Started by klumpke
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I have looked at the AKS in detail and the two stark criteria for ASC’s. I don’t see how it is possible for most physicians to meet both points of Stark with e and m payment going up and procedure payment being static or going down. It needs to be revised.
From what I've read, you dont technically have to meet the 1/3 of income at ASC requirement, it just becomes a bit trickier to defend legally to regulators if the situation arises. Is that true?
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Yes, that is true. Safe Harbor are guidelines but the inspector will look at the totality of facts. The example they used were low volume neurosurgeons in an ASC.
How do you do eat what you kill model in the ASC? Doesnt that go against the whole point of ASC share ownership?
you do not have to
It is quite common practice in orthopedic ASCs, as far as I understand, to distribute a specific percentage of the net revenue directly to the surgeon, while the remaining amount is distributed equally among all shareholders. My observation is that pain providers are almost always among the top revenue generators, if not the highest ones.
We have several locations, I’m in two of them. One has a clinic procedure suite, the other only has an ASC. Two days per week I’m in that location with the ASC.
If I did ALL of my procedures, and I’m doing procedures 4 days per week, if ALL of them were ASC I’d be the highest collecting doctor in the practice in terms of ASC money.
Wow nice. What would you say is your ratio of B&B:Advanced procedures at the ASC?
Like nearly every other pain doctor in America, your traditional spinal injections will be around 90-95% of what you do. An RFA done well and done fast is prob our best procedure overall.
I meant from a dollar standpoint rather than procedure numbers, like is 90-95% of your ASC income coming from B&B procedures?
I couldn’t give you that number bc I don’t know it. Your collections are not from stim. That’s obviously more lucrative, but I’d much rather do trials in the clinic, not the surgical center.
When we get our end of year ASC reports, there isn’t a breakdown by procedure type. We just get total procedures, costs, gross and net revenue.
I do know the biggest hitter is a bcbs IPG exchange. They pay the same as an implant.
Okay got it thanks for the help understanding guys.
I am still confused that in the thread about ASC ownership that most practice owners wouldnt offer ASC ownership shares unless someone was doing a good amount of advanced stuff, but it sounds like majority of docs are doing relatively very few advanced procedures proportionally. Can you explain for me?
I am still confused that in the thread about ASC ownership that most practice owners wouldnt offer ASC ownership shares unless someone was doing a good amount of advanced stuff, but it sounds like majority of docs are doing relatively very few advanced procedures proportionally. Can you explain for me?
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Anything we do in the ASC is either going to be the same or much better than the other surgeons. My partner was more profitable per hour than everyone but me and he only had around 50 cases and a fair amount of them were RFA’s. He did less than 20 SCS and PNS implants. I would take any pain doctor as a minority owner in the center as long as they do a little bit of SCS and don’t try to sneak any experimental stuff that doesn’t pay.
Things like shoulder scopes are profitable on a per case basis but not really when you look at all of the time spent blocking, getting the patient under anesthesia and positioned, prepped and getting access with the scope. Takes a long time. Which is why ortho very much wants to flip rooms, which ends up costing a lot of money in extra staff and the anesthesia group would much rather have one provider so that one gets all of the cases since I think they are paid by the day.
Ortho guys take forever to do anything. They simply will not do anything to help either, whereas I am helping to turn the room over. I strip sheets off the bed, pull trays, grab meds, raise the table, etc. I don’t flip rooms, and the only thing slowing me down is the nurse bringing the pt back. The ortho guys are in the dictation room talking and sending emails and BS’ing.
There will every once in a while be a guy who is exceptional, and it is usually a hip and knee guy. We had one and I can’t get into why he left us on an open Internet forum.
He was doing many dozens of totals per month. Entire practice was set up around him and we had fantastic rates with our payers for totals.
If you’re a pain doctor doing 250 or so procedures per month in an ASC you’re going to blow them out of the water in ASC collections, but if you don’t own a significant percentage of that ASC you need to take those procedures to your clinic procedure room and your professional collections will pop.
There will every once in a while be a guy who is exceptional, and it is usually a hip and knee guy. We had one and I can’t get into why he left us on an open Internet forum.
He was doing many dozens of totals per month. Entire practice was set up around him and we had fantastic rates with our payers for totals.
If you’re a pain doctor doing 250 or so procedures per month in an ASC you’re going to blow them out of the water in ASC collections, but if you don’t own a significant percentage of that ASC you need to take those procedures to your clinic procedure room and your professional collections will pop.
We can do WC injections, ablations in the ASC and we get paid the same as the office. Couple implants and a couple WC basic procedures is a peaceful, profitable short ASC session.
Yeah, battery swap CPT is the same as the implant CPT without the lead component.
I don’t think I knew that
Private insurance a lot of times handles it different in the ASC compared to Medicare. For the ASC, Medicare pays per code. Private insurance will just pay a set amount for 63685, then the 63650’s are bundled. Same for trials. Private insurance will pay the same for a single lead trial or a 4 lead DRG trial. Medicare will pay per lead. Oddly, in the HOPD Medicare will pay the same for an implant or battery swap.
Yeah, it's weird but the CPT codes is insertion or replacement if new battery vs revision or removal if no battery change needed
| CPT | Description |
| 63685 | Insertion or replacement of spinal neurostimulator pulse generator or receiver requiring pocket creation and connection between electrode array and pulse generator or receiver |
| 63688 | Revision or removal of implanted spinal neurostimulator pulse generator or receiver, with detachable connection to electrode array |
whats the margin per pain case?
Can you elaborate on what you mean by this? It would seem to me that if you get paid the same in office you’d be far better off doing them all in office - taking stuff to the ASC is usually a smaller piece of a bigger pie. Are they only paying you the pro fee regardless and no global fee in office?
So for OK work comp, we get paid around $300 for an epidural no matter where we do it. If we do it at an ASC, we still get $300 and the ASC will get the facility fee of around $1200. So we do them at the ASC.
But it isn’t when you only have 5-12% ownership in the ASC and can only do 3-4 cases per hour in the ASC vs 6-7 per hour in your office that you own 100%.
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We operate under a distinct model. In our practice, you’ll receive substantial financial benefits from performing injections in the ASC rather than in the office. Approximately, I earn my professional fee plus around 80% of the facility fees after deducting costs.
Are you saying your dividend from the ASC is relative to the surgical volume you take to the ASC, not to your percent ASC ownership? If so, the OIG would like a word.
In my last group, the pain doc before me had a similar type of set up where his only site of service was an asc and he was provided with a site of service “differential” which essentially was a kick back in addition to the distributions the asc made. It was a great arrangement for him until it wasn’t..surgeons got sour, started implementing all this “tax” like call tax and other measures to claw the money back from him.
Example from my neck of the woods: I did two kyphos last week. 1 lvl each. One was Medicare, one was WC. I don't know the facility fee because I did both at a hospital, but my pro fee for Medicare was the usual ~$480 which was effectively a charity case. My WC Pro fee was $5800.
I had a similar deal with two stims I did. Did them at a local ASC where I own no shares. One got Medicare fees which are crap. Only agreed to do it because I did the trial and told the patient I'd do her implant. The second implant that day was WC and it paid ~8k in pro fees to me.
I want to be a WC kypho expert now!
Oh, I’m in CA so I don’t think we get that sort of thing.
So it seems ortho in the ASC has very slim margins. What specialties other than pain are good ones to have at the ASC? Ophtho cranking cataracts? GI?
Also, what other specialty can crank out the vast majority of their cases without anesthesia? Several colleagues that I know own highly efficient ASCs and do all their procedures under no sedation or nursing sedation. This helps with the speed and volume pain docs produce
Also, what other specialty can crank out the vast majority of their cases without anesthesia? Several colleagues that I know own highly efficient ASCs and do all their procedures under no sedation or nursing sedation. This helps with the speed and volume pain docs produce
Yeah, CA I believe has fixed WC rates. Where I am, we negotiate with the WC companies, and we generally get paid 70-80% of our billed charges.
This is the university-based orthopedic group, the largest in the state. We carefully review all laws to ensure that sharing is a legal process.
Not sure what your lawyers have said but any system that ties your individual dividends to the volume of cases you bring to the center is unequivocally illegal under Stark and AKS. Dividend can only be proportional to the percentage of the center you own. Participating in such a system exposes you to civil and criminal penalties.
what state is this? I am in TX so I am looking to see if I can get close to that on the pro-fee
This is correct.
This doesnt explain anything.
If you are getting paid more money from the facility fees for bringing more cases in, that is a direct and unequivocal violation of AKS and Stark Law.
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Perhaps the practice can be structured in a way to do this but not an ASC and the ASC ownership.
Thanks for your opinion. I had to go back and talk to our CEO to ask for this. Our structured practice is able to share the ASC bonus in a favorable way from the OIG. Some other practices have adopted this model actually.
Ah, so the practice owns the shares rather than the individual doctors?
Can you describe the workaround in more detail?
We just lost a guy to another practice under this same setup and our lawyers could not state it was legal. Not sure if there are state specific issues there or not, wouldn’t be under federal law I don’t think. The reality is that no one here truly knows what they’re talking about when it comes to the nuance of this stuff.
