PM&R (and Pain) Consults at ALF vs. ILF vs. SNF

[milomoneepood]

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I am here to request guidance and knowledge from the wise and experienced please.


A brand new PM&R and Pain attending in the private world here. I would like to diversity my practice by building outside consults. I have a psychiatrist friend who told me that he searched nursing homes, ALF’s and ILF’s in town on Google, just cold-called and/or showed up in person at those facilities to drop off his CV and requested to get credentialed to do psych consults. He said many of them credentialed him quickly and he was able to build his consult practice at multiple nursing homes, ALF’s and ILF’s, and his biller is able to bill for the consults… so I assume the residents’ insurance??. The friend said as a psychiatrist he doesn’t need referrals to do consults at those places and can just go do consults at ALF/ILF/nursing home after being credentialed with respective facilities.


(1) My question as a PM&R for nursing homes, ALF’s and ILF’s - can I also do the same and go without primary care referrals as long as the facilities credential me? I assumed even for nursing homes, ALF’s and ILF’s that I as a physiatrist would need referrals from the facility primary doctors/MLP’s before being able to see their patients as consults - like doing consults at SNF’s.

(2) If I can go to nursing homes/ALF/ILF - what would be the points of emphasis to appeal to those facilities that I am worthy of their credentialing as a physiatrist, and who would I “bill”? Because I would think the residents at ALF/ILF/nursing homes are likely self-pay, unless their insurances can be billed?

(3) For PM&R consults at SNF’s, do these facilities like to have PM&R consults for their patients to have rehab specialists documentation to justify their patients to stay to continue therapy 1hr/day during their admission? (and/or maybe to keep the patients longer?) As a trainee a few years ago doing intermittent SNF rounds with my attendings, I simply did the work that I was told to do but never felt the need to understand why we were there leaving PM&R consult notes for those rather stable patients.. Now I am trying to understand the business aspect from the SNF’s perspective on why the SNF’s would let physiatrists come to do consults on their patients and bill for them…. so that I can better advocate for myself to build business with them. Obviously I can say I am also Pain trained and can do pain management as a bonus, but it would mean that I would have to find a SNF who already doesn’t have a PM&R consultant available, convince the SNF administration to let me get credentialed, and also “earn” the consults from the primary medicine team to do 3 consults/week. Would this be a correct assumption?

(4) If I “can” bill for the consults at ALF/ILF/nursing home, what codes for I use? or is it even possible?

(5) For PM&R (or Pain) consults at SNF, what codes do I use to bill?


Thank you very much in advance!

 

[RangerBob]

Hopefully someone will correct me if I'm wrong. But I believe SNFs require the primary to consult you just like an acute care hospital. Otherwise it's fraud. If a consult is required as it is at an acute care hospital/inpatient rehab, then a whistleblower basically could get half the money Medicare claws back from you (ie., there's quite an incentive to report someone).

So I hope your friend is right about SNFs not requiring consults, but I don't think they are--SNF patients are managed by a primary attending, and the nursing home residents have PCPs who manage them--in which care a referral is needed (if pt has a PPO I guess they can usually self-refer).

Patients in ALF/ILF are more-or-less like outpatients at "home." You would bill their insurance, then bill the patient for the balance. Whether credentials are needed probably depends on the facility--they're not regulated the way SNFs/acute care hospitals are. Whether a referral is needed, well, I would imagine that depends on insurance, but also every facility may operate differently as far as their particular facility protocol.

Some SNFs like PM&R consulting, some don't--completely depends on the facility/director. As a general rule, the way to sell yourself to them is to say you'll manage pain/bowel/bladder/"rehab" needs, run team conferences, and help patients go home more independently. Be clear on expectations though--are you covering those issues 24/7, or just making recommendations to the primary? Usually you can see patients twice a week. Maybe three if there's a lot going on? Again, hopefully some SNF physiatrists can chime in more.

The bigger question is how much of this is worth it.

I can't see ILF/ALF consults being worth it unless it's a big facility or easy to get to (on the way to/from work already), and you'll have a steady stream of referrals (I'm going to assume for the moment you need the referrals). You'll get paid probably around what you get paid for an outpt visit, but you're having to go visit them (which you may find rewarding, but it does take time/money to get there). I don't know about the complexities of billing for home visits, but it all just sounds like a lot of hassle for likely not a lot of financial benefit. But it may be personally gratifying, which can go a long way in life.

SNFs I can see more financial benefit from, as you typically have a larger population to work with, and they have more clearly defined needs (both traditional rehab needs as well as likely a lot of patients with pain issues). They're also usually so grateful that a doctor is actually seeing them, so while they're not as functional as the ILF/ALF patients, this can be gratifying as well.

I know some pain docs, at least historically, liked to cover acute rehab units--it kept up their traditional rehab skills and they often found patients who would benefit from following up with them in their clinic. And if you do any injections/etc that's always a major plus. This applies for the SNFs as well, but acute rehab patients have shorter LOS, so you're seeing more patients and thus generating more potential follow-ups. Since you're seeing the patient as an inpatient, typically a referral isn't needed from most insurances for them to follow up with you (but this can vary).

Acute care pain consults could be quite advantageous as well--again, particularly if you do injections. Market yourself right and I'm sure you'd make friends and get lots of consults. Of course, you'd need to be available pretty regularly (ideally daily M-F, but for a consult service to thrive you really want 7d/week coverage). I'm not sure how doing injections on inpatient pays, but it may be worth looking into, particularly if you have a hospital near your clinic.