Providing contract work and TMS at same location?

[finalpsychyear]

Trying to figure out the logistics of a scenario. Currently providing med management at a location where I am an hourly contractor. They have no desire for rTMS due to costs but are happy to "give" me an extra room if i were to buy a machine/hire staff/etc and provide services there for their patients who are heavily Medicaid who does cover it now in my state. I also have a 1 day a week PP in a different area so i am credentialed with all ins. except medicaid.

Would I have to update my existing insurance contracts to include this service location since my NPI is already used with their TIN for med managment at the same location?

Or rather do i need to officially have a private address like a specific suite in the same building or an office down the street completely separate and pay for this as a monthly rent for this to actually work?

I am very confused about this if anyone can shed light would be helpful.

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[TexasPhysician]

1. If you don’t have a high volume of insurance patients, this is likely a bad idea financially. Machines, staffing, etc are expensive. You need to keep the machine purring so to speak to make anything. Most practices obtain patients by internal referrals. Those that don’t usually lease a suite from a large outpatient insurance practice. Rarely I see psychiatrists make a name for themselves doing only treatment resistant depression. Think TMS, ketamine, Spravato, Botox, etc.

2. Credentialing 2x in the exact same mailing address is possible with different EIN’s, but Insurance companies will likely mess it up from time to time. Your payments could go to the other business (current contracting company) or the opposite which will upset your current relationship if you don’t work together well on this.

 

[finalpsychyear]

1. If you don’t have a high volume of insurance patients, this is likely a bad idea financially. Machines, staffing, etc are expensive. You need to keep the machine purring so to speak to make anything. Most practices obtain patients by internal referrals. Those that don’t usually lease a suite from a large outpatient insurance practice. Rarely I see psychiatrists make a name for themselves doing only treatment resistant depression. Think TMS, ketamine, Spravato, Botox, etc.

2. Credentialing 2x in the exact same mailing address is possible with different EIN’s, but Insurance companies will likely mess it up from time to time. Your payments could go to the other business (current contracting company) or the opposite which will upset your current relationship if you don’t work together well on this.

1. its a CMHC so no issues for patients.

2. Even if i am already credentialed in the state but adding just an extra location to an existing TIN/NPI combo it is still an extensive process? I would have all mail sent to my other office for simplicity.

3. any idea if you have to be in network for medicaid managed care to offer TMS but i believe there is such a thing as single case agreements if i am not mistaken esp since no one in the area does rTMS.

Thanks for the response and any additional feedback you have.

 

[splik]

As it is likely some of these patients have medicare, it could be a stark law violation for them to "give" you space for free to have an rTMS clinic to serve their patients. You need to work with attorney for this arrangement. In addition, you need think about whether it will be worth it to accept medicaid pts. 90868 should typically be at least $300. I would be surprised if medicaid would reimburse reasonably for TMS unless you are in one of those states where medicaid reimburses well.

For commercial insurances, you may need to negotiate your contracts for TMS coverage as well. In my area, some big commercial insurances pay extremely well for TMS but there are also many clinics for this that it typically wouldn't make sense for a solo practitioner to offer this.

 

[finalpsychyear]

As it is likely some of these patients have medicare, it could be a stark law violation for them to "give" you space for free to have an rTMS clinic to serve their patients. You need to work with attorney for this arrangement. In addition, you need think about whether it will be worth it to accept medicaid pts. 90868 should typically be at least $300. I would be surprised if medicaid would reimburse reasonably for TMS unless you are in one of those states where medicaid reimburses well.

For commercial insurances, you may need to negotiate your contracts for TMS coverage as well. In my area, some big commercial insurances pay extremely well for TMS but there are also many clinics for this that it typically wouldn't make sense for a solo practitioner to offer this.

Medicare in my area pays half that in my area so i guess that means medicaid is even worse likely. My estimate for the overhead cost of the machine/staff/rent 3000-3500/mo. So setting up a rent space in the same building or near the clinic seems like the best idea but i guess the overall plan may break even when costs taking into consideration.

Splik/Texas question for you. If there is a service address and my NPI/TIN combo is used my the contract agency (they use their TIN as of now with my NPI) do i need to have a distinct address for another NPI/TIN combo like suite 1,2,3 etc or is the differing npi/tin combo distinct already and can be at the same address?

 

[TexasPhysician]

Medicare in my area pays half that in my area so i guess that means medicaid is even worse likely. My estimate for the overhead cost of the machine/staff/rent 3000-3500/mo. So setting up a rent space in the same building or near the clinic seems like the best idea but i guess the overall plan may break even when costs taking into consideration.

Splik/Texas question for you. If there is a service address and my NPI/TIN combo is used my the contract agency (they use their TIN as of now with my NPI) do i need to have a distinct address for another NPI/TIN combo like suite 1,2,3 etc or is the differing npi/tin combo distinct already and can be at the same address?

I don’t think you need a different suite number.

No one is doing TMS with Medicaid outside of academia that I’ve seen. Trained staff with TMS plus the machine and rent for $3k/month is shockingly low.

 

[finalpsychyear]

the numbers are low because its based on 20 hours of staff time. Full time the numbers are likely double. The machine is also 2nd hand refurb but right now this is just in planning phase. just found out the medicare rt is abt 150 so this is probably not going to work in the end as i imagine medicaid is even worse 😔😭

 

[clozareal]

why do you have to buy the machine and hire staff if its their patients and you are contracted hourly with them? they should front those costs and deal with the billing if you are treating medicaid patients and then give you an hourly rate to do this. what they are proposing to you is no different than just leasing an office in any old building except for free.

 

[finalpsychyear]

why do you have to buy the machine and hire staff if its their patients and you are contracted hourly with them? they should front those costs and deal with the billing if you are treating medicaid patients and then give you an hourly rate to do this. what they are proposing to you is no different than just leasing an office in any old building except for free.

I can lease the machine in a renting model. The admin hadn't heard of rTMS before so... The break even point even at 100-150/scan is 2 patients who do M-F for 4 weeks. The lease can be terminated at any time. So i thought the investment isn't huge and maybe it grows to non medicaid at some point?

 

[calvnandhobbs68]

I can lease the machine in a renting model. The admin hadn't heard of rTMS before so... The break even point even at 100-150/scan is 2 patients who do M-F for 4 weeks. The lease can be terminated at any time. So i thought the investment isn't huge and maybe it grows to non medicaid at some point?

Remember, medicaid patients you can't bill no show fees. Also likely to have worse than baseline transportation and many life issues that may prevent them from getting to a place on time reliably 5 days a week. So getting them there 5 days a week for 4 weeks is a big ask, on top of crappier medicaid reimbursements and no way to incentivize them to actually show up with no show fees.

 

[finalpsychyear]

As it is likely some of these patients have medicare, it could be a stark law violation for them to "give" you space for free to have an rTMS clinic to serve their patients. You need to work with attorney for this arrangement. In addition, you need think about whether it will be worth it to accept medicaid pts. 90868 should typically be at least $300. I would be surprised if medicaid would reimburse reasonably for TMS unless you are in one of those states where medicaid reimburses well.

For commercial insurances, you may need to negotiate your contracts for TMS coverage as well. In my area, some big commercial insurances pay extremely well for TMS but there are also many clinics for this that it typically wouldn't make sense for a solo practitioner to offer this.

Found out the rate for medicaid/medicare is 145/160. Moreover even private ins at best ranges from 160-200 in this area. So doing 20 scans would cover the overhead roughly.