In just a few short years, the methods and efficiencies of pain management claims reimbursement have undergone dramatic changes. Thanks in large part to the adoption of the more complex ICD-10 codes, pain management practices are finding it increasingly difficult to meet both federal regulators’ and payers’ demands.

For example, providers are now asked to have pre-authorizations on file before providing procedures. These in turn will be approved only if providers are able to show evidence that such services are required and other more conservative therapies have been ineffective. Additionally, payers now have set more stringent limits and guidelines on how many times physicians can perform these procedures.

Providers once accustomed to receiving payment in 30 days are now seeing claims delayed for up to 180 days, usually due to being targeted for review. Payer questions pertaining to the diagnosis, the number of times procedures are expected to be performed, what treatments have been used previously and proof of the extent of successful pain reduction for the patient are becoming routine aspects of the local coverage determination (LCD).

Obviously, submitting pain management claims under these circumstances offers more chances for errors and missed deadlines. What can pain management practices and other providers do to stay on top of all of these changes and complex regulations?

Partnering with an experienced revenue cycle management company can ensure a more robust revenue cycle from faster and complete reimbursements, while creating relationships among payers and other organizations benefiting from your practice as their local pain physician.

Manage Pain Treatment Programs and Therapies From a Clinical Viewpoint

According to a prominent ambulatory surgical center organization, pain centers and other providers need to be proactive in managing costs of procedures, and recommend starting with relatively simple epidurals and moving from there, if necessary, to more complex treatments such as radiofrequency ablation. In addition, pain centers need to know the costs of performing a procedure at a clinic versus a surgical center, with some payers now allowing certain procedures to be performed in a physician’s office.

New pain treatment guidelines from the American College of Physicians as well as the CDC recommending inclusion of non-pharmacological alternative treatments can be problematic, as many payers are reluctant to reimburse newer and possibly clinically unproven other alternative therapies for what they consider “experimental” treatments. These may adversely impact a pain center’s reimbursement rates, so knowing whether as well as how much a procedure is payable up front is essential when considering appropriate therapies.

Managing medication is a major concern for both providers and payers, especially given the current opioid crisis. Providers are often blamed for excessive pain medication prescriptions absent clinical measures for overseeing the management of medication, stressing the need for careful oversight.

The use of technology, such as with implants that offer more focused and effective relief and neuro-stimulator pain pumps, and adding physical therapy or behavioral health services can boost your professional standing while increasing revenues.

Pain Management Billing and Contract Negotiation

When negotiating with payers, it is critical that providers and pain center managers know treatment costs at the clinical levels, and that they communicate this knowledge with both the revenue cycle managers and your practice’s contracting divisions. Smart center managers and other pain care providers are turning to financial analytics for data concerning the patient populations affected, workflow complexities and other elements of the business. Your practice management team can help with these processes.

Evaluating the true costs of your most-performed procedures can help determine if the reimbursements justify the expenses. Performing frequent analyses of your billing cycle can determine if costs are in line with nationwide costs and reimbursement levels for pain procedures. Awareness of your costs as well as full and accurate documentation can be leveraged at contract negotiation time.  Familiarity with the marketplace at large is also a critical component of maintaining strong revenue processes.

Don’t Forget the Basics

Finally, as mentioned here in an earlier blog, pay attention to the basics that can affect your pain management billing cycle, including verifying coverage information and eligibility. Thoroughly documenting services and need in submitted claims is a key to full reimbursement.
Strive for transparent communication between your front office and patients regarding their payment obligations once insurance has met theirs. A recent TransUnion Healthcare study showed that during 2017 patients experienced a jump of 11 percent in average out-of-pocket healthcare expenses. Explaining financial obligations up front before the time of services is the best way to avoid unpleasant surprises for many cash-strapped patients.

What to Look for When Evaluating Pain Management Billing Service – 

• Your claims should be handled by dedicated processing specialists experienced in workers compensation, no-fault and other payers’ pain management regulations.
• Coding mistakes account for most delayed and denied claims – a pain management billing specialists should understand and be experienced in using the unique coding of pain management; 
• Payer pre-authorizations should be obtained and kept on file, unless a new authorization is required for each procedure. Having a billing service that understands and works closely with a variety of payers and knows their specific requirements is one of the biggest advantages of using a good medical billing service.
• A good medical billing company should additional services to manage your revenue cycle, such as A/R management for patients as well as insurance, changes and demographics in patients and enrollments, account analysis to learn payer patterns and where your practice may be “leaking” money from unpaid but payable) claims and other sources.

As a leader in the medical billing and claims management industry, M-Scribe has been helping practices and facilities of all sizes and specialties with their medical billing and management needs since 2002. Contact us at 770-666-0470 or email us to learn more about how we can ensure that your pain management and other kinds of claims are billed correctly, regardless of payer, for full and faster payment.

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