New TPI restrictions?

[drusso]

I'd like to do cash pay for these, but medicare won't let you charge for a covered service, even if they don't pay enough to justify doing it. I have been sending more pts to a local PT who does good dry needling

This is just more ammunition for cash-pay procedures. It makes life easier for everyone.

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[drusso]

Sadly, I have to factor in what the market will bear. It sickens me that my vet can charge $600 for a BS ultrasound, and people will IMMEDIATELY pull out their card, but try charging a pain patient $200 cash for something and they can't find their wallet.

For services that have a high rate of success, I have no problem charging a fair cash rate and sticking to it. Trigger points, PRP, PRF, etc.. meh.

Just have the patient sign an ABN and offer it for cash.

 

[CleanUp]

TPIs would be great if I did a bunch of med mgmt and bread and butter procedures without spending much time with patients. That’s not what I want in my practice, though.

Many patients don’t know the difference between a SCS implant and TPI. That means they’ll expect their daughter to call and go over everything extensively. And if they have a spasm I will get called on a Saturday. And when it wears off they will say the pain is worse. And then I’ll try to educate them why muscle relaxers aren’t safe for someone 85 years old or how opioids aren’t indicated. Then my staff will ask if it is lidocaine or machine and give me a 3.5 inch needle despite all the training showing them exact pictures of what to draw up. Then the next patient will get pissed because I’m late.

All for a trigger point injection.

 

[sdnuser001]

What if you just bill for a Toradol injection? Is that a workaround or too much drop in reimbursement?

 

[bedrock]

What if you just bill for a Toradol injection? Is that a workaround or too much drop in reimbursement?

I don't have the exact numbers but the drop is significant. I think a toradol injection IM is about $7, while a TPI is about $55 (medicare).

Not even worth the time to do just a toradol injection, I would either do nothing further or I'd just tell my assistant to send in a medrol pack, while I then move to the next room.

 

[bedrock]

TPIs would be great if I did a bunch of med mgmt and bread and butter procedures without spending much time with patients. That’s not what I want in my practice, though.

Many patients don’t know the difference between a SCS implant and TPI. That means they’ll expect their daughter to call and go over everything extensively. And if they have a spasm I will get called on a Saturday. And when it wears off they will say the pain is worse. And then I’ll try to educate them why muscle relaxers aren’t safe for someone 85 years old or how opioids aren’t indicated. Then my staff will ask if it is lidocaine or machine and give me a 3.5 inch needle despite all the training showing them exact pictures of what to draw up. Then the next patient will get pissed because I’m late.

All for a trigger point injection.

Where do you practice?
It seems you indulge your patients a bit too much.

1- If a patients family calls or want to do a phone call during a visit, my staff is trained to tell them I don't offer that.
(Any family member is welcome to accompany any patient to an office visit, but I will not work for free which is what a phone call is).
so I never ever speak with a family member outside of an office visit.
2- If a patient called about a non urgent medical matter on a weekend, my staff/answering service tells them to check back in during business hours. The if answering service is uncertain, then I do have to answer it, and I gently let the patient know that their phone was inappropriate and and not an emergency. If the patient does it again, they are fired from the practice.
3- Bummer you can't get your staff to draw things up correctly. Do you work with many different staff members? I only trained two of them and they mess up occasionally, but rarely as the only in office procedures I routinely perform are 1- TPI, 2- GON/LON blocks, 3- troch bursa injections, 4- peripheral joint injections. I do expect my staff to be able to remember just 4 types of meds to draw up for those 4 types of same day office procedures.

 

[powermd]

TPIs would be great if I did a bunch of med mgmt and bread and butter procedures without spending much time with patients. That’s not what I want in my practice, though.

Many patients don’t know the difference between a SCS implant and TPI. That means they’ll expect their daughter to call and go over everything extensively. And if they have a spasm I will get called on a Saturday. And when it wears off they will say the pain is worse. And then I’ll try to educate them why muscle relaxers aren’t safe for someone 85 years old or how opioids aren’t indicated. Then my staff will ask if it is lidocaine or machine and give me a 3.5 inch needle despite all the training showing them exact pictures of what to draw up. Then the next patient will get pissed because I’m late.

All for a trigger point injection.

Where is this, California?

 

[CleanUp]

Where do you practice?
It seems you indulge your patients a bit too much.

1- If a patients family calls or want to do a phone call during a visit, my staff is trained to tell them I don't offer that.
(Any family member is welcome to accompany any patient to an office visit, but I will not work for free which is what a phone call is).
so I never ever speak with a family member outside of an office visit.
2- If a patient called about a non urgent medical matter on a weekend, my staff/answering service tells them to check back in during business hours. The if answering service is uncertain, then I do have to answer it, and I gently let the patient know that their phone was inappropriate and and not an emergency. If the patient does it again, they are fired from the practice.
3- Bummer you can't get your staff to draw things up correctly. Do you work with many different staff members? I only trained two of them and they mess up occasionally, but rarely as the only in office procedures I routinely perform are 1- TPI, 2- GON/LON blocks, 3- troch bursa injections, 4- peripheral joint injections. I do expect my staff to be able to remember just 4 types of meds to draw up for those 4 types of same day office procedures.

You are partially correct and I haven’t given the entire story. Most patients read where I went to for med school, residency, and fellowship and tell me they expect to be wowed. So, I think it self selects for the more entitled and elitist? By the way I’m not special at all. Just giving perspective.

Poor manager = high staff turnover = no real training for the MAs= when asked they just forward to me which ends up more work for me. To put this into perspective one MA didn’t know what “prn” meant. Another didn’t even enter in the patient's pharmacy in ECW. A third wrote down “lower” for the laterality.

Partners in the group practice the same way so this is the culture and expectation. In my estimation this is tolerated because they are surgeons.

Patients have also been conditioned by other physicians they see (concierge).

Cannot easily fire a patient given state and healthcare entity rules. Essentially chronic pain patients are deemed a protected class in the legal sense I was told. They can be fired yes but it takes a ton of work and time.

Overall I’m very happy and fortunate to have learned all these lessons. It truly has led to something better financially and for my own headspace.

 

[Laryngospasm]

You are partially correct and I haven’t given the entire story. Most patients read where I went to for med school, residency, and fellowship and tell me they expect to be wowed. So, I think it self selects for the more entitled and elitist? By the way I’m not special at all. Just giving perspective.

Poor manager = high staff turnover = no real training for the MAs= when asked they just forward to me which ends up more work for me. To put this into perspective one MA didn’t know what “prn” meant. Another didn’t even enter in the patient's pharmacy in ECW. A third wrote down “lower” for the laterality.

Partners in the group practice the same way so this is the culture and expectation. In my estimation this is tolerated because they are surgeons.

Patients have also been conditioned by other physicians they see (concierge).

Cannot easily fire a patient given state and healthcare entity rules. Essentially chronic pain patients are deemed a protected class in the legal sense I was told. They can be fired yes but it takes a ton of work and time.

Overall I’m very happy and fortunate to have learned all these lessons. It truly has led to something better financially and for my own headspace.

That sounds hellish.. I would burn out in a year.

 

[bedrock]

You are partially correct and I haven’t given the entire story. Most patients read where I went to for med school, residency, and fellowship and tell me they expect to be wowed. So, I think it self selects for the more entitled and elitist? By the way I’m not special at all. Just giving perspective.

Poor manager = high staff turnover = no real training for the MAs= when asked they just forward to me which ends up more work for me. To put this into perspective one MA didn’t know what “prn” meant. Another didn’t even enter in the patient's pharmacy in ECW. A third wrote down “lower” for the laterality.

Partners in the group practice the same way so this is the culture and expectation. In my estimation this is tolerated because they are surgeons.

Patients have also been conditioned by other physicians they see (concierge).

Cannot easily fire a patient given state and healthcare entity rules. Essentially chronic pain patients are deemed a protected class in the legal sense I was told. They can be fired yes but it takes a ton of work and time.

Overall I’m very happy and fortunate to have learned all these lessons. It truly has led to something better financially and for my own headspace.

In which state do you practice?

 

[manowar rules]

This is one of the underrated aspects of practicing in a more rural area. My staff don’t act like they’re too good for their jobs. My patients are generally grateful. And they bring me fresh eggs.