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17 JOINT VENTURES Pain Management in 2017: Tips for Thriving Despite the Challenges Written by Jereen Mathew, MBA, Senior Vice President, Operations, and Tamara Wagner, CPC, Vice President, Performance Review, National Medical Billing Services T he methodology and efficiency of reim- bursement for pain management pro- cedures has drastically changed over the past few years. Gone are the days when you could simply bill the procedure and get paid within 30 days. e industry has evolved to incorporate more stringent policies that regulate the use of pain medications. We have also seen changes in payer policies on notifications, coverage and reimbursement. Since ICD-10 went into effect in October 2015, centers have found it increasingly diffi- cult to meet the demands of payers and federal regulators for pain management procedures. Payers are now asking physicians to obtain pre-approvals (provide notifications) prior to providing the procedures. e procedures are only approved if providers can show adequate evidence that services are required and other conservative therapies have failed. Payers have specific guidelines and limitations regarding how many times the physicians can perform the procedures. Providers are also facing post- service, prepayment coding reviews. When physicians follow their routine interventional pain procedures that have been effective in the past, the reimbursements are now oen get- ting denied by the payers. Payers are also limiting what services can be performed in surgery centers and are shiing certain procedures to the physicians' offices, thereby reducing their costs. Physicians who are accustomed to being paid in 30 days are seeing payments held up as long as 180 days because the claims are oen flagged for review. To obtain approval, you must prove that the procedures are warranted and that the evi- dence is documented in the medical record. You must show a complete picture, including a full history of the patients. Physicians face the chal- lenge of following more detailed requirements in the local coverage determinations (LCDs), including questions concerning what is the diag- nosis, how many times the procedure has been performed, whether more conservative and alter- native methods have been tried, and how much the patient's pain has been reduced. Physicians face more controls on prescribing combinations of drugs and complex drugs. e big question? Whether the treatment was needed and is a prov- en pain management procedure that works on a particular patient's body. Payers have also started denying procedures because they consider certain treatments to be "experimental" and not proven effective even though other insurance companies may have been reimbursing for the same procedures for years. We have also read recommendations from the CDC, and new guidelines from the American College of Physicians suggest the addition of al- ternative methods of pain treatment that are non- pharmacologic in nature. How do your providers and your center make money when payers don't reimburse for some of these alternative therapies? Providers aren't the only ones feeling over- whelmed. Payers have not been prepared for the deluge of pain management claims or the amount of time required to review them to en- sure that they meet their guidelines. ey are contracting with beneficiary advisory compa- nies to handle approvals. Medication management is another critical concern that providers need to understand. With a growing epidemic in which people are becoming highly dependent on their pain medication, many physicians are being tar- geted for overprescribing pain medication without any clinical measures for managing the prescribed pain medication. With these many guidelines and regulations, payer policies, and prepayment/post-service coding reviews, reimbursement for pain man- agement isn't what it used to be. erefore, growing this business line is more difficult and takes an increasing amount of work. You must understand the payer guidelines, determine what needs to be done to take care of patients, and stay within the guidelines. e stakes are high because pain procedures oen provide significant revenue. e good news is that there is much room for growth. Pain affects more Americans than can- cer, diabetes, and heart disease combined, with the number of potential patients reaching into the millions, according to the American Acad- emy of Pain Medicine. You can be paid success- fully for these procedures, and even increase your business, if you take the right steps. Your patient population is key. While you still want to cater to the Medicare and Medicaid popula- tions, you must grow your business and have patients with commercial and workers' comp insurance to stay competitive. Many pain management centers are start- ing their treatments with simple procedures, such as epidurals and, as needed and within payer guidelines, progressing to more com- plex procedures such as radiofrequency ab- lation (RFA). Centers should be innovative in understanding and managing the costs of these therapies. It is also critical to manage your programs from a clinical perspective. You must understand what is happening at the clinical level so you can know, for example, what the costs are to perform a procedure in a clinic versus a surgery center. Knowing these costs is critical for contract negotiations. Negotiating a contract is much more than just accepting a contract and sign- ing on the dotted line. To take advantage of the opportunities in pain management, it is im- portant to be involved with your contracting division and your revenue cycle company. It is highly advisable to approach contract negotia- tions as a science with financial analytics and a thorough understanding of the business, the patient population, and the complexities of the workflows that are involved – before the pa- tient even gets on the table. You should evalu- ate the costs of your top procedures and deter- mine whether the reimbursements justify the costs. Understanding the overall marketplace is also critical. With strong contract manage- ment and robust revenue cycle processes, you can obtain the reimbursements that make eco- nomic sense to run your business. Work with your business development team to look for strategic partnerships that will benefit from having you as their local pain physician. Such payers are looking for the right providers that their members can visit. Having strong refer- ral sources in your local market is helpful to bringing in new patients. Using technology to move beyond the old-fash- ioned treatments of simple injections can help benefit patients and centers. Newer implants, for example, are much smaller, focused, and more effective. Exploring and adding services can open new revenue streams. Other new treatments include neuro-stimulation, pain pumps, interspinous spacer procedures, as well as new technology for the dorsal root ganglion stimulators. Centers also are extending their services to areas such as physical therapy and behavioral health to complement the core busi- ness. Several have also figured out ways to pro- vide durable medical equipment (DME) to help patients manage their pain.