Understanding facility reimbursement

IPSIS: Formerly the Spine Intervention Society
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Ahh good to.see the spinal industrial complex is still a force and running smoothly. The pain doc in the ortho group is a cog in the machine. Spine surgeon sends you a patient for esi after already telling the patient that the esi is just a temp thing to get them the fusion the patient needs. The fusion is the solution and the esi is the bandaid the patient needs until the surgery...
You do the esi
Patient goes back to surgeon to get fused. You see them months later for continued pain

The surgeon has already told them that their back was the worst back he has ever seen and it looked far worse then what the mri showed. He tells the patient He did the best he could given how bad their back was and tells the hardware looks great and the back is stabilized and the previous impending risk of paralysis is gone
You do tf esi at the adjacent segment. And the so-called band aid is.placed again. The patient goes back to surgeon to get adjacent.level fusion.

Several months later the surgeon refers back to the in-house pain doc for continued pain
And here two paths are available depending on the ortho practice you are in. You will either stim them or you opioid or continue their opiods.

Then patient still has pain and you do SI joint block patient will tell you yeah it worked because the patient is always looking for "the solution" and you or the surgeon then do the SI joint fusion.
After several hundred thousand health care dollars spent the spinal industrial complex churns on. The ortho is happy, the hardware reps and hardware companies are happy, the ASC is fed with facility fees and prosperous. And the pain doc in this ortho practice is the vital bandaid that gives the surgeon time to stagger cases ... and the pain doc gets some crumbs from the spine surgeon too, ie. Patients with bad insurance or too much co morbidities. Those patients you do your therapeutic esi's and rfa's
 
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Buff n turf
 
jsaul said:
Ahh good to.see the spinal industrial complex is still a force and running smoothly. The pain doc in the ortho group is a cog in the machine. Spine surgeon sends you a patient for esi after already telling the patient that the esi is just a temp thing to get them the fusion the patient needs. The fusion is the solution and the esi is the bandaid the patient needs until the surgery...
You do the esi
Patient goes back to surgeon to get fused. You see them months later for continued pain

The surgeon has already told them that their back was the worst back he has ever seen and it looked far worse then what the mri showed. He tells the patient He did the best he could given how bad their back was and tells the hardware looks great and the back is stabilized and the previous impending risk of paralysis is gone
You do tf esi at the adjacent segment. And the so-called band aid is.placed again. The patient goes back to surgeon to get adjacent.level fusion.

Several months later the surgeon refers back to the in-house pain doc for continued pain
And here two paths are available depending on the ortho practice you are in. You will either stim them or you opioid or continue their opiods.

Then patient still has pain and you do SI joint block patient will tell you yeah it worked because the patient is always looking for "the solution" and you or the surgeon then do the SI joint fusion.
After several hundred thousand health care dollars spent the spinal industrial complex churns on. The ortho is happy, the hardware reps and hardware companies are happy, the ASC is fed with facility fees and prosperous. And the pain doc in this ortho practice is the vital bandaid that gives the surgeon time to stagger cases
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So what’s your day to day practice look like?
 
When I brought up the concept of professional fees vs facility fees my group said they don’t count facility fees (they own the ASC). They are now my former group.

I can’t run 4 rooms at once like they can. I can’t “hit a home run” with a big case. If the turn over is slow I’m screwed. The orthopod can book 12 cases and call it a day. My staff books 2-3 times that. I still gotta pay my staff. Overhead goes up. Still takes time and money for these pellets.
 
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RoloTomassi said:
Same. I rarely do stim. Chronic opioid population is the best way to get stims
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MitchLevi said:
Exactly the reason I am the way I am. I could get authorization for tons of stimulators but I don’t bc I think it’s a very limited therapy that only works for a small number of diagnoses.
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callmeanesthesia said:
Me too but I don’t see that many great SCS candidates. Lots of adjacent segment disease, degenerative foraminal stenosis, etc, but not so much of the “hurts all the time” back and leg nerve damage type of pain. Maybe it’s a function of the local surgeons? They’re all pretty conservative, very reasonable guys.
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Agree.

Most stim candidates come from
1- patients on chronic opioids, and they’ve become tolerant to the meds, so they are desperate.
2- overly aggressive spine surgeons

If you don’t do COT, and/or your local spine surgeons are not overly aggressive, then not many stim patients come your way.

Unfortunately even most of those #1&#2 patients are desperate but ultimately fail SCS.

As I said before, most “stim candidates” are not going to be happy with SCS long term, because SCS just doesn’t consistently treat pain above the belt, and most of the pain in the desperate patients I mentioned in #1 and #2 is above the belt.
 
If you have a developing practice it takes some time to find Intracept candidates. I like them to have failed facet interventions , esi etc before moving to it. Plus having an older population makes it easier. Look at every mri. Many have modic changes and go from there. It really does work for 60-70% of the patients that I have treated so far
 
Ronin1 said:
If you have a developing practice it takes some time to find Intracept candidates. I like them to have failed facet interventions , esi etc before moving to it. Plus having an older population makes it easier. Look at every mri. Many have modic changes and go from there. It really does work for 60-70% of the patients that I have treated so far
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I’m getting trained in 3-4w
 
SpineandWine said:
That being said, I do 350 procedures in month- just mostly ESIs and SI
Still not as lucrative as I thought in Medicare based population
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What’s your practice model? If office based you should easily be collecting 1 million plus annually just on procedures.

ASC based without ownership maybe 350-500 on based on ownership. Making bank for the ASC owners though.

HOPD. You are making them 3 M plus a year. Wrvu at least 10k assuming u have some office visits.

It’s all just math
 
SpineandWine said:
That being said, I do 350 procedures in month- just mostly ESIs and SI
Still not as lucrative as I thought in Medicare based population
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How the f can you do that many procedures in a month? Do you have a mid level or two? When do you have time to see patients to set them up
 
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Ronin1 said:
What’s your practice model? If office based you should easily be collecting 1 million plus annually just on procedures.

ASC based without ownership maybe 350-500 on based on ownership. Making bank for the ASC owners though.

HOPD. You are making them 3 M plus a year. Wrvu at least 10k assuming u have some office visits.

It’s all just math
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Its not nearly as lucrative as that if mostly ESI or SI
I have only one mid level, I work hard and power through clinic/do most notes afterwards
 
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SpineandWine said:
That being said, I do 350 procedures in month- just mostly ESIs and SI
Still not as lucrative as I thought in Medicare based population
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for ASC or HOPD, 350 procedures/month x 12 months x $95 (averaging ESI at 102 and SI at 89) = 399,00 on professional fees alone. add in facility fees, which an ASC would charge on average $300 for $1.2 million, on top of the $400k.

for office based practice, at a low end of an average of $200 an injection, you would be bringing in at least $890,000 on base medicare rates.



that doesnt include the office visits and new patient evals.


but i am having difficulty comprehending that you are doing 17.5 ESI and SI injections each and every work day.

and not seeing any patients at all.
 
Here’s a better question…who is diagnosing (incorrectly) all of that SIJ pathology?
 
SpineandWine said:
That being said, I do 350 procedures in month- just mostly ESIs and SI
Still not as lucrative as I thought in Medicare based population
Click to expand...
That is a MONSTROUS amount of procedures and cannot imagine how you’d churn that volume with one mid level, but you should be making 1M per yr EASILY. With office visits and ancillary added you’re in the top 1% in our field. Very few ppl do procedure numbers like that, and those that do are generally supported by a very large team of midlevels and scribes and MAs.
 
I somewhat infer from his posts that he is doing a lot of direct injects in the ASC. I don’t think we are doing that many procedures in our office and we have myself and about 1/2 FTE physician.
 
Agree. Sounds like surgeons are putting injections onto his ASC procedure block.

Dude, please get a clinic procedure suite if that’s in any way possible.
 
MitchLevi said:
Agree. Sounds like surgeons are putting injections onto his ASC procedure block.

Dude, please get a clinic procedure suite if that’s in any way possible.
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Why would they do that. They are all benefiting off of those juicy facility fees.

This kind of set up also is a liability IMO. I don’t do direct referred injections anymore unless it’s a hip and even then I’m doing a mini h&p and have canceled quite a few because of it .
 
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Ronin1 said:
As much as u may like the volume. This is the definition of a block shop. So take the experience and move on to something with a future
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This is way more than any block shop I’ve ever heard of
 
So my last job this guy I knew was going like 35-40 procedures 4.5 days/week. Honestly I thought that was the norm and I had more ways to go.

I’m surprised @BobBarker that you’re not hitting this no with your prior posts on volume/seeing patients
 
SpineandWine said:
So my last job this guy I knew was going like 35-40 procedures 4.5 days/week. Honestly I thought that was the norm and I had more ways to go.

I’m surprised @BobBarker that you’re not hitting this no with your prior posts on volume/seeing patients
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Hang on man…How many clinic visits do you have per week?
 
MitchLevi said:
Hang on man…How many clinic visits do you have per week?
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The only way to get to those numbers is Medicare practice and all direct referrals for shots, no clinic time, unless 84 hour work week..but even then
 
Me and the other doctor were in office a total of 6 days last week and maybe 55 total injections were done.
 
BobBarker said:
Me and the other doctor were in office a total of 6 days last week and maybe 55 total injections were done.
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Difference being you’re generating all those procedures yourselves.

The busiest I’ve ever been is when I did 235 spine injections in 3 weeks. Dec ‘22. Had I not taken a week off at Christmas for a family trip, I would have prob pushed 300 that month, but it was destruction for my staff and generating those injxns required a lot of sweat in the clinic.

The number of phone calls that many procedures generate is significant, and it requires a lot of help. You also run into more and more denials and documentation issues.

At least, that’s my experience.
 
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MitchLevi said:
Difference being you’re generating all those procedures yourselves.
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We have 25 surgeons in group.
So I have these patients eval and rx for “right L5-S1 TFESI”, say hi to them and book. Honestly some of easiest consults of my life- all MRIs uploaded and medical necessity done by PT before they see me

since mostly surgical patients, if TFESI or ILESI don’t work, they go back so large outflux hence only one APP- if injections work, I ask they call me PRN if it’s been three months

***
Some direct bookings as well ~5% as some come from far away
 
SpineandWine said:
We have 25 surgeons in group.
So I have these patients eval and rx for “right L5-S1 TFESI”, say hi to them and book. Honestly some of easiest consults of my life- all MRIs uploaded and medical necessity done by PT before they see me

since mostly surgical patients, if TFESI or ILESI don’t work, they go back so large outflux hence only one APP- if injections work, I ask they call me PRN if it’s been three months

***
Some direct bookings as well ~5% as some come from far away
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Are you doing ablations if the ESI fails?
 
SpineandWine said:
We have 25 surgeons in group.
So I have these patients eval and rx for “right L5-S1 TFESI”, say hi to them and book. Honestly some of easiest consults of my life- all MRIs uploaded and medical necessity done by PT before they see me

since mostly surgical patients, if TFESI or ILESI don’t work, they go back so large outflux hence only one APP- if injections work, I ask they call me PRN if it’s been three months

***
Some direct bookings as well ~5% as some come from far away
Click to expand...
This is a very poor care model
 
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SpineandWine said:
If primarily axial back pain and facets as pain generator
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So, the surgeons send to you for management and you refer back if everything fails? That’s my set up.

Basically, “Refer to Dr Leavitt (me) for management until they need surgery.”

Only a very few of these internal referrals ever see the surgeon again bc I manage everything myself. I might send one pt per month back to the surgeons. Some months no one gets sent back. Perhaps 10-12 per yr I send for surgery.
 
SpineandWine said:
Why?
They’ve done PT, I give neuropathic meds, they have acute radic, I try steroid injections
The surgeons see like a kajillion patients for me to be able to have this practice
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Patients generally want some time spent with them. To just say hi let me give you a date for your shot doesn’t seem like anything that would fly where I’m at. Just don’t get the sheer volume if you actually spend at least 5-10 minutes with them. Don’t they want to see the mri? The surgeons in my group rely on me to show them the mri.
 
It seems that you are dissatisfied with your income based on your posts? Is this is your model, doing ASC procedures in a place with no ownership? You are generating a lot of income for someone.
 
Dr. Ice said:
Patients generally want some time spent with them. To just say hi let me give you a date for your shot doesn’t seem like anything that would fly where I’m at. Just don’t get the sheer volume if you actually spend at least 5-10 minutes with them. Don’t they want to see the mri? The surgeons in my group rely on me to show them the mri.
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How do you set up your practice?
 
SpineandWine said:
How do you set up your practice?
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Ortho, patients sent to me for intervention. I don’t take direct referrals for shots. I eval all of them before deciding on a procedure except hip injections and even those I’m screening beforehand. 3 clinic days 2 procedure days. I’m a 4% owner of an asc. Very very little med management.

The model is going to change as historically I’ve seen very few new patients because surgeons would see all the news and then send to me for intervention after PT. It’s apparently going to change with the addition of a mid level under me.
 
Dr. Ice said:
Ortho, patients sent to me for intervention. I don’t take direct referrals for shots. I eval all of them before deciding on a procedure except hip injections and even those I’m screening beforehand. 3 clinic days 2 procedure days. I’m a 4% owner of an asc. Very very little med management.

The model is going to change as historically I’ve seen very few new patients because surgeons would see all the news and then send to me for intervention after PT. It’s apparently going to change with the addition of a mid level under me.
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Do you feel you’ll do same interventions with new patient evals
You’ll order PT, then MRI, then meds, f/u MRI and then consider injection therapy - lots of visits, less intervention

Hip injections make like 40 bucks in facility
Adding clinic visit = 200

your 240 vs. my 40
I honestly don’t do any evals (I’ve had to cancel because of DMx2 but then create follow up to optimize)or follow up for hips
 
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MitchLevi said:
The number of phone calls that many procedures generate is significant, and it requires a lot of help. You also run into more and more denials and documentation issues.

At least, that’s my experience.
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This was my experience as well. The more injections I did the more staff I had to hire so the overhead ballooned. The more “hey doc just one question” slowed me down and crammed my inbox. My staff became dissatisfied because their work load went up. The team become an insatiable beast because I always had to hire new people. And that means I had to spend more time training them. I hired someone to do peer to peers and prior auths which were money losers.

All for what?
 
SpineandWine said:
Yeah I agree.
I am going to try and slow down.
There is another pain doc hired so should help
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Who manages your post procedural issues like failed shots, worse pain, neuritis, insomnia, etc?
 
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