Understanding facility reimbursement

[SpineandWine]

Who manages your post procedural issues like failed shots, worse pain, neuritis, insomnia, etc?

Me or my APP.
I prep them for failed shots or worse pain though
As mentioned I work a lot, will slow down soon. Trying to do more clinic

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[CleanUp]

Yeah I agree.
I am going to try and slow down.
There is another pain doc hired so should help

Don’t feel bad. Live and learn. My friend was in a similar situation. He was being fed a ton of injections. Thought he was secure. Turns out the ortho group only valued him for injections and nothing else. In the ortho eyes they could easily hire a new grad or a more experienced pain physician without business acumen to do the same thing. The moment my friend wanted a more equitable sharing of the profit he was deemed not to be a team player. He was then replaced with a lower cost option. That lower cost option was replaced by an even lower cost option! He’s in a much better place now and grateful for what he learned.

 

[Dr. Ice]

If we cheapen ourselves to fit “the model” the cycle will perpetuate. You are a doctor, not someone’s monkey to do “the shot.” What makes surgeons believe they know what to order? Do you tell them what surgical approach to take? Many times the spine surgeon doesn’t know what the hell to order. They will ask for a snrb and if you question they will be like “can you just do the shot.” F that..

 

[Agast]

Hired needles will eventually be replaced by pain CRNAs

 

[SpineandWine]

Hired needles will eventually be replaced by pain CRNAs

Fair point

 

[bedrock]

Hired needles will eventually be replaced by pain CRNAs

Exactly

 

[geauxg8rs]

Exactly

Especially when they won’t question what injection to do. You want a tfesi at L5-S1 even though the problem is at L3-4, they will do that and of course next step is fusion

 

[Dr. Ice]

The happiest docs I know are those working with like minded individuals. The biggest mistake I made was joining an ortho group from the start. Now the cycle will just continue.

 

[sloh]

Ortho exploits pain. Pp pain doc exploits the young pain docs. W2 cog in the wheel. What are the options?

 

[ErrantWhatever]

Seeking genuine advice on a related topic:

I’m very fortunate to receive a partnership offer in a growing ortho practice. It’s a great group of surgeons who are committed to a culture of quality patient care. I’ve been here for a year and have been performing all of my fluoro procedures at an ASC of which the practice owns about 25%.

My question is about moving some procedures to in-office. Running the available reimbursement numbers from 2020 on the ASIPP site (not a member), when adding up my pro fee and 25% of the facility fee in the ASC, many bread and butter procedures would overall result in greater income for the practice itself from office-based procedures (and toward my % collections I’d be switching to). I have a good relationship w the ASC administrator and he basically said my quick injections are pretty revenue neutral and in office may make sense for many reasons.

1) When I’ve brought this up in the past, the founding partner states they’ve sought carve outs from commercial carriers and no one is interested. I’ve had to educate myself a bit and state that these are basic injections and likely no local carriers would do exclusive carve outs for in office procedures with us. Am I missing something here? Do you have to negotiate reimbursement rates with each carrier for in office fluoro procedures?

2) Would it be reasonable to put in on me to purchase a c arm and table? Some threads in the past suggest this. I’d likely be the only one using it, so I get it. My biggest concern is that I likely will have to take out a big bank loan to buy in. So I may just have to table this topic for a bit till I could swing the cost of the equipment.

3) Do any of you find ASC injections cumbersome? Part of the reason I’m also very interested in developing in-office procedures is the hassle of the ASC. I’m given limited time and am booking out further and further. This makes it tough particularly trying to care for folks w acute radics. Additionally, there’s about 6 signatures per patient and it gets old after the 12th injection. ASC staff also clearly start getting toasty after the 10th injection while next door the surgeon is only on his second shoulder scope.

That’s a lot of words. I’ve spent the last week reading through old threads on this topic and appreciate any updates on advice.

 

[Dr. Ice]

Ortho exploits pain. Pp pain doc exploits the young pain docs. W2 cog in the wheel. What are the options?

Hospital rapes docs for sos and facility fees. There’s no good way. I could have if I had strong entrepreneurial spirit started my own thing years ago. At a measly 170k in loans, I was fearful. Now the guys coming out due to 400k in loans won’t go out on their own and so the cycle of exploitation will continue on and on forever

 

[Dr. Ice]

Seeking genuine advice on a related topic:

I’m very fortunate to receive a partnership offer in a growing ortho practice. It’s a great group of surgeons who are committed to a culture of quality patient care. I’ve been here for a year and have been performing all of my fluoro procedures at an ASC of which the practice owns about 25%.

My question is about moving some procedures to in-office. Running the available reimbursement numbers from 2020 on the ASIPP site (not a member), when adding up my pro fee and 25% of the facility fee in the ASC, many bread and butter procedures would overall result in greater income for the practice itself from office-based procedures (and toward my % collections I’d be switching to). I have a good relationship w the ASC administrator and he basically said my quick injections are pretty revenue neutral and in office may make sense for many reasons.

1) When I’ve brought this up in the past, the founding partner states they’ve sought carve outs from commercial carriers and no one is interested. I’ve had to educate myself a bit and state that these are basic injections and likely no local carriers would do exclusive carve outs for in office procedures with us. Am I missing something here? Do you have to negotiate reimbursement rates with each carrier for in office fluoro procedures?

2) Would it be reasonable to put in on me to purchase a c arm and table? Some threads in the past suggest this. I’d likely be the only one using it, so I get it. My biggest concern is that I likely will have to take out a big bank loan to buy in. So I may just have to table this topic for a bit till I could swing the cost of the equipment.

3) Do any of you find ASC injections cumbersome? Part of the reason I’m also very interested in developing in-office procedures is the hassle of the ASC. I’m given limited time and am booking out further and further. This makes it tough particularly trying to care for folks w acute radics. Additionally, there’s about 6 signatures per patient and it gets old after the 12th injection. ASC staff also clearly start getting toasty after the 10th injection while next door the surgeon is only on his second shoulder scope.

That’s a lot of words. I’ve spent the last week reading through old threads on this topic and appreciate any updates on advice.

Asc is crap. The whole thing makes no sense for us. Everyone doing shots there has a vested interest and that interest will poison rational thinking and propagate talking up the facility as a “safer” place to get a procedure done. I’m saying this as a small percentage owner in an asc myself. I hate going there. It’s extraordinarily inefficient and to ask people about how many beers they drink a week for a 4 minute shot really makes no sense.

But I do it..and the reality is even for bread and butter and the time it takes for us, our margins are better (based on contracts of course) than surgical margins because of the sheer cost of equipment. So, this ridiculous conversation will continue to come up over and over until everything goes site neutral..which it won’t

 

[Agast]

Seeking genuine advice on a related topic:

I’m very fortunate to receive a partnership offer in a growing ortho practice. It’s a great group of surgeons who are committed to a culture of quality patient care. I’ve been here for a year and have been performing all of my fluoro procedures at an ASC of which the practice owns about 25%.

My question is about moving some procedures to in-office. Running the available reimbursement numbers from 2020 on the ASIPP site (not a member), when adding up my pro fee and 25% of the facility fee in the ASC, many bread and butter procedures would overall result in greater income for the practice itself from office-based procedures (and toward my % collections I’d be switching to). I have a good relationship w the ASC administrator and he basically said my quick injections are pretty revenue neutral and in office may make sense for many reasons.

1) When I’ve brought this up in the past, the founding partner states they’ve sought carve outs from commercial carriers and no one is interested. I’ve had to educate myself a bit and state that these are basic injections and likely no local carriers would do exclusive carve outs for in office procedures with us. Am I missing something here? Do you have to negotiate reimbursement rates with each carrier for in office fluoro procedures?

2) Would it be reasonable to put in on me to purchase a c arm and table? Some threads in the past suggest this. I’d likely be the only one using it, so I get it. My biggest concern is that I likely will have to take out a big bank loan to buy in. So I may just have to table this topic for a bit till I could swing the cost of the equipment.

3) Do any of you find ASC injections cumbersome? Part of the reason I’m also very interested in developing in-office procedures is the hassle of the ASC. I’m given limited time and am booking out further and further. This makes it tough particularly trying to care for folks w acute radics. Additionally, there’s about 6 signatures per patient and it gets old after the 12th injection. ASC staff also clearly start getting toasty after the 10th injection while next door the surgeon is only on his second shoulder scope.

That’s a lot of words. I’ve spent the last week reading through old threads on this topic and appreciate any updates on advice.

I’ve spent a lot of time thinking about this. Currently the cost of building a procedure room and purchasing equipment plus the supplies and medications that are needed, do not make sense for me. Remember pro fees are higher in office to offset the cost of materials. However if there were two very active pain physicians to split the cost it becomes more reasonable. The only way I see your group willing to share the costs of maintaining your procedure room and C-arm is if you stay an employee so they can take a cut off your collections in perpetuity.

I don’t think your simple injections are revenue neutral unless they are grossly mismanaging their operating costs.

 

[Dr. Ice]

I’ve spent a lot of time thinking about this. Currently the cost of building a procedure room and purchasing equipment plus the supplies and medications that are needed, do not make sense for me. Remember pro fees are higher in office to offset the cost of materials. However if there were two very active pain physicians to split the cost it becomes more reasonable. The only way I see your group willing to share the costs of maintaining your procedure room and C-arm is if you stay an employee so they can take a cut off your collections in perpetuity.

I don’t think your simple injections are revenue neutral unless they are grossly mismanaging their operating costs.

This is probably true..In the current economic times, I can’t speak to the cost of creating a procedure suite. I was in a similar situation a few years ago. There were two of us in an ortho group. My predecessor was all asc based but created a site of service differential payment for himself which was satisfactory for many years for all parties involved until I came on board and ortho was then confronted with having to pay both of us the site of service fee. Then they built an in office procedure suite. Now there’s only me working there. They probably paid off the expense of the suite and the refurbished c arm by now but it’s been 7 years.

Errantwhatever..maybe you can carve something similar to a site of service differential (questionable legality) although probably doable as part of some bonus, if creating an office space doesn’t work mathematically right now.

 

[bedrock]

Seeking genuine advice on a related topic:

I’m very fortunate to receive a partnership offer in a growing ortho practice. It’s a great group of surgeons who are committed to a culture of quality patient care. I’ve been here for a year and have been performing all of my fluoro procedures at an ASC of which the practice owns about 25%.

My question is about moving some procedures to in-office. Running the available reimbursement numbers from 2020 on the ASIPP site (not a member), when adding up my pro fee and 25% of the facility fee in the ASC, many bread and butter procedures would overall result in greater income for the practice itself from office-based procedures (and toward my % collections I’d be switching to). I have a good relationship w the ASC administrator and he basically said my quick injections are pretty revenue neutral and in office may make sense for many reasons.

1) When I’ve brought this up in the past, the founding partner states they’ve sought carve outs from commercial carriers and no one is interested. I’ve had to educate myself a bit and state that these are basic injections and likely no local carriers would do exclusive carve outs for in office procedures with us. Am I missing something here? Do you have to negotiate reimbursement rates with each carrier for in office fluoro procedures?

2) Would it be reasonable to put in on me to purchase a c arm and table? Some threads in the past suggest this. I’d likely be the only one using it, so I get it. My biggest concern is that I likely will have to take out a big bank loan to buy in. So I may just have to table this topic for a bit till I could swing the cost of the equipment.

3) Do any of you find ASC injections cumbersome? Part of the reason I’m also very interested in developing in-office procedures is the hassle of the ASC. I’m given limited time and am booking out further and further. This makes it tough particularly trying to care for folks w acute radics. Additionally, there’s about 6 signatures per patient and it gets old after the 12th injection. ASC staff also clearly start getting toasty after the 10th injection while next door the surgeon is only on his second shoulder scope.

That’s a lot of words. I’ve spent the last week reading through old threads on this topic and appreciate any updates on advice.

One option you should have in your toolbox is doing cases at the ASC, but flipping two rooms. I'm part of an ortho practice. The previous doctor didn't do this, but I was able to convince them to let me run two rooms on my ASC days.
So I'm now able to do 38-40 cases on an ASC day (injections and RFA), but a bit less if bigger case like SCS/intracept.
I was previously doing 22-24 cases a day with one room and typical ASC speed, so being able to almost double my ASC production made partnership more valuable

Getting your own office based procedure room can be great, but if they really don't want you to do that, then asking then to let you flip two ASC rooms is an option you should consider.

 

[SpineandWine]

One option you should have in your toolbox is doing cases at the ASC, but flipping two rooms. I'm part of an ortho practice. The previous doctor didn't do this, but I was able to convince them to let me run two rooms on my ASC days.
So I'm now able to 40 cases on an ASC day (injections and RFA), a bit less than 40 if bigger case like SCS.
I was previously doing 25 cases a day with one room and typical ASC speed, so being able to almost double my ASC production made partnership more valuable

Getting your own procedure can be great, but if they really don't want you to do that, then asking to flip two rooms is an option you should consider.

Now wait just a minute.
40 procedures in day- how many you hitting a month?

 

[Taus]

One option you should have in your toolbox is doing cases at the ASC, but flipping two rooms. I'm part of an ortho practice. The previous doctor didn't do this, but I was able to convince them to let me run two rooms on my ASC days.
So I'm now able to 40 cases on an ASC day (injections and RFA), a bit less than 40 if bigger case like SCS.
I was previously doing 25 cases a day with one room and typical ASC speed, so being able to almost double my ASC production made partnership more valuable

Getting your own procedure can be great, but if they really don't want you to do that, then asking to flip two rooms is an option you should consider.

Phew…. Sounds exhausting. Do you have a fluffer to take care of all the pre/post bs to allow you to go room to room and just do procedures most of day? Ie not having to see patients in pre-op, have them sign consent, mark side, computer orders pre, dictate and dispo stuff after?

I do 30/day in office (less if rfa)…. Can’t really picture myself doing more.

 

[MitchLevi]

Plenty of ortho groups that do not exploit pain doctors...Man, some of you are jaded af bc you got hosed but there are plenty of us that aren't.

 

[bedrock]

Phew…. Sounds exhausting. Do you have a fluffer to take care of all the pre/post bs to allow you to go room to room and just do procedures most of day? Ie not having to see patients in pre-op, have them sign consent, mark side, computer orders pre, dictate and dispo stuff after?

I do 30/day in office (less if rfa)…. Can’t really picture myself doing more.

Nurses help them with consent, mark sides, etc. I just sign on my line. 95% of these patients were seen by me in the last two weeks, so not many changes. I also use procedure templates, so 90% of my notes take 15 seconds to dictate. I just add the side, and anesthesia. Standard post op orders depending on type of case.
I do take 30 minutes the day before to write a list of the the sedation amounts for patients getting IV, and how many weeks for follow up as that can differ based on patient situation.

Plenty of ortho groups that do not exploit pain doctors...Man, some of you are jaded af bc you got hosed but there are plenty of us that aren't.

Same here. I am a full partner at my ortho practice getting the same share of ASC/MRI/PT revenue as the other partners and the same vote with practice issues. I also personally evaluate 99% of my patients and only do a handful of direct injections each year for urgent patients.

That said, I definitely had to jump through more hoops to become a partner compared with the new surgeons, but in the end I have the same financial benefits and equal vote on all important practice matters.

 

[BobBarker]

If you have space/walls up (15’ x 15’) then it costs about 100k in equipment and maybe $10k in refurbishing the space for in office. About $2500/month on a 60 month note.

 

[bedrock]

Now wait just a minute.
40 procedures in day- how many you hitting a month?

230-240.

As I mentioned today in the private forum, I have learned that I only get paid double for medicare and cigna patients, but otherwise leaving revenue on the table for our practice ancillary revenue if any other payor is done in my office procedure suite.

So I do one ASC flip day each week, one per week, so four ASC flip days per month at about 38-40 cases each ASC flip day.

I also do 3 office based procedure days each month, (only 3 out of the 4 weeks), for medicare and cigna patients, and for any insurance SIJ (Because SIJ doesn't pay facility fee). I average 25 cases on the office based days, partially because that staff isn't as fast, particularly between RFA patients.

I generally do IV sedation with cervical RFA on most Cigna patients which are done on my ASC days. All SCS in ASC, as the ortho partners definitely want the SCS facility fee.

Otherwise, all other Medicare and Cigna procedures done in office.

So about 75 cases each month in the office and 155-160 in the ASC.

This way I contribute my fair share to the practice ancillaries, but simultaneously maximize office based revenue on medicare/cigna patients.

 

[RoloTomassi]

Do you have to negotiate reimbursement rates with each carrier for in office fluoro procedures?

Yes. But they're probably already in your current contracts since you've been getting pro fees for the same codes.

2) Would it be reasonable to put in on me to purchase a c arm and table?

Depends on how overhead is handled. Should be spelled out in operating agreement.

3) Do any of you find ASC injections cumbersome?

Completely dependent on how well oiled the ASC is.

 

[agolden1]

230-240.

As I mentioned today in the private forum, I have learned that I only get paid double for medicare and cigna patients, but otherwise leaving revenue on the table for our practice ancillary revenue if any other payor is done in my office procedure suite.

So I do one ASC flip day each week, one per week, so four ASC flip days per month at about 38-40 cases each ASC flip day.

I also do 3 office based procedure days each month, (only 3 out of the 4 weeks), for medicare and cigna patients, and for any insurance SIJ (Because SIJ doesn't pay facility fee). I average 25 cases on the office based days, partially because that staff isn't as fast, particularly between RFA patients.

I generally do IV sedation with cervical RFA on most Cigna patients which are done on my ASC days. All SCS in ASC, as the ortho partners definitely want the SCS facility fee.

Otherwise, all other Medicare and Cigna procedures done in office.

So about 75 cases each month in the office and 155-160 in the ASC.

This way I contribute my fair share to the practice ancillaries, but simultaneously maximize office based revenue on medicare/cigna patients.

This is an awesome setup. When a group is open to discussion and aware of the differences in reimbursement between locations, you can end up with really cool results like this.

Several of the ortho practices I’ve spoken with were kind of negative towards their pain docs with a negative outlook. Cool to see that even if it took a little doing you were able to make this happen.

 

[agolden1]

Plenty of ortho groups that do not exploit pain doctors...Man, some of you are jaded af bc you got hosed but there are plenty of us that aren't.

There are great HOPD/PP/ortho jobs and there are terrible HOPD/PP/ortho jobs.

Sometimes it just feels like in our field there’s a few more of the terrible gigs out there, so finding a “great” or earning the money to develop your own takes more time.

 

[Taus]

Nurses help them with consent, mark sides, etc. I just sign on my line. 95% of these patients were seen by me in the last two weeks, so not many changes. I also use procedure templates, so 90% of my notes take 15 seconds to dictate. I just add the side, and anesthesia. Standard post op orders depending on type of case.
I do take 30 minutes the day before to write a list of the the sedation amounts for patients getting IV, and how many weeks for follow up as that can differ based on patient situation.




That’s still A LOT in a day. I have a bit more to do than that for my Asc days in terms of pre/post procedure work and less than that on my office procedure days. I’m about 75% office procedures. Also do about 30 minutes of prep per day, particularly as I do take direct procedure referrals, some from my PMR/Pain partners who do not do cervicals and/or Rfa and some from spine surgeons and spine PAs. In an ideal world, I would request evaluation in office for every single one… But I am booked out about six weeks in the office and just don’t have it. I catch/address any issues ahead of time during my prep, which I do about a week before the procedure day.

 

[ErrantWhatever]

Appreciate all the responses. I’m going to take some of these ideas to the group.

In terms of the proposed procedure room, the practice just opened a large clinic space with a 20x20 (-ish?) “procedure room” without a clear idea who would be doing what there. There’s a hand guy who does percutaneous carpal tunnel releases in office and I think he was in mind. So I believe the main investment would be a c arm and procedure table.

Thanks again.

 

[BobBarker]

C arm/procedure table/rf generator are $100k

 

[RoloTomassi]

100k is relatively cheap but if they balk at it you can also throw out the option to lease or lease-to-own c-arm. A few cases a month should cover that cost

 

[BobBarker]

You can put it all on a 60 month loan. Pretty cheap monthly after 20% down.