Episode 91: Things Every Pain Doc Needs To Know About Billing w. Devona Slater

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This Episode

Interview w/ Dr. Brian Cohen

You Will Learn

– Important documenting procedures that many practices forget to do which can cause bigger problems down the line
– The differences between medical practice billing and business practice billing
– What is a net collections rate, and what it means to have a healthy net collections rate

Resources & Links

I’m excited to have Devona Slater back to address the pain management side of the billing and coding complexities and landscape. Devona joined us in episode 88 breaking down the fundamentals of anesthesia billing, how the money flows from the procedure to when the practice gets paid and everything in between.


Justin (00:03):
This week, I’m really excited to be joined by Devona Slater. Once again, she joined us a couple of weeks ago to talk about billing and anesthesiology. Today we’re tackling billing and pain management. We answer a number of important and interesting questions about how billing actually happens. Why is it important that physicians keep on top of best billing practices? What key metrics you be looking at as a physician to understand if you’re getting paid appropriately? What are the the ENM evaluation and management coding changes that happened this year? What are the challenges that you face with in-house billing versus with an outsource billing solution, these and many other questions we’re going to tackle in today’s conversation as always, thanks for joining.

Justin (01:05):
Hello and welcome to episode 91 of APM success. I’m very pleased to be joined again by our special guest of honest later, Devona joined us a couple of weeks ago in episode 88, which if you haven’t heard that, you’re gonna want to check it out. I got just lots of amazing feedback. Like this is really valuable. This is incredible. I’ve never heard anything like this, about breaking down the fundamentals of anesthesia billing, how the money flows in terms of, from the procedure to when the practice gets paid and everything in between. It’s not straightforward. Believe it or not. I’m sure you’d probably do believe it. So really excited to have Devona back to address now the the pain management side of the billing and coding complexities and landscape. She is the president and senior compliance auditor for ACE, which is auditing for compliance and education, which is a consulting company that specializes in anesthesia and pain management, billing and compliance. So Devona, thanks a lot for being back here as a guest.

Devona Slater (01:56):
My pleasure, my pleasure.

Justin (01:59):
So I mean, billing and coding, this is it’s something that I realized early on. I, I really have enjoyed going to the practice management track meetings at Asmara specifically where I have just, it has been so eye opening, the business complexities that physicians need to deal with and understanding billing and coding, making sure that you’re getting paid properly on the procedures that you’re doing on the the ENM that you’re providing for patients. And that you’re not opening yourself up to liability. There’s, there’s a lot that you need to sort of be up to speed on that isn’t really related to clinical medicine necessarily. So I’m excited to dive in and learn from your expertise here. For starters, just share a little bit about the work that you do specifically for either pain management physicians or anesthesia anesthesiologists who do a fair amount of pain as well. How do you interact with that cohort of professional? What do you do for them? Sure. So

Devona Slater (03:00):
Basically I would start with the auditing process of what we’re doing. We’re trying to go in and, and basically assess their documentation and see that it supports the codes that are billed, of course, and then check on the reimbursement of that. You know, I was like to think of it as a kind of your physical checkup, at least annually, that you do a little bit of going in and just kind of tearing the system apart to make sure that those things do balance each other out w you know, the goal is, is to have a perfect audit and not have any findings. So that’s the goal. We rarely find that to be quite honest, and there are different challenges based on different locations. So in the office setting, you know, those physicians actually have to pay a whole lot more attention to costs and whether or not that global payment that Medicare and many of the, the provider or the insurance companies pay is enough to really cover those costs and make money versus your hospital side, who just built for the professional services. So they do both have to pay attention to CPT ICD 10 hixpix Cody, but it’s a lot more important, I guess. Although you can get in trouble in either setting, so let’s be clear just because you work in a hospital setting, does it make your free and clear of, of being charged with problems? So, yeah,

Justin (04:36):
A couple of interesting points I want to zoom in on I’m curious for the practices that you see that are very compliant, very on top of billing and coding and understand that dynamic and are proactive. How frequently are they engaging someone like you or, or another third party to give them that objective feedback? Is it an annual thing, or is it every few years

Devona Slater (04:57):
It’s probably a annual or every other year? I would tell you that the clients that we deal with, it’s not unusual for me to get questions every month from their billing and coding staff and have a really good ongoing relationship. Many times something will just come up that it’s just, it’s not that we don’t understand what we’re doing. We do. It’s just, they need some verification or validation or somebody maybe to do a little bit more. One of the things that’s come up recently is the infusion therapy. It’s a big deal right now in the pain community. And there really are not any CPT codes that support what we’re doing. And so understanding what needs to be documented, what they need to bill for. And that that’s really probably a cash basis service, because most of the insurance companies for chronic pain consider that experimental and investigational. So, yeah, so I mean, understanding those kinds of components and helping them put together a process. So they’re not working for free that is extremely important and in the pain community, because they do do a lot of cutting edge kinds of things to help these patients.

Justin (06:16):
Yeah. So you, you mentioned a couple of different types of codes, the ICD CPT, and HCPCS families maybe briefly describe what are those mean? And in which practice settings are they wrong?

Devona Slater (06:29):
Oh, sure. The office let’s start with them. You know, everybody is going to use the CPT codes, which tells you what you do. What did you do for the patient then ICD 10 really says, why did you do it? So they were in pain, we’re dealing with narcotic management, we have lumbar spondylosis, whatever is the problem. So that’s really your ICD 10. And then your hip fix is really your drugs and supplies. And again, in the office setting, those are the codes that we see a lot of times are misinterpreted or don’t, you know, groups get it wrong. And again, the supplies are bundled. Anything with an, a code in front of it is a bundled supply code in the Medicare system. So that’s important for physicians to understand and in managed care contracting then is important for them to know whether or not they can charge separately for those kinds of things on the hospital side. Yeah. We just do CPT and ICD tech. So what are you doing and why are you doing it?

Justin (07:37):
Got it. So for the let’s what you just described in the Hicks picks, can you, can you maybe zoom in on that and explain a little bit more about what you mean as far as understanding the, the challenges that physicians face, the mistakes they’re making with the supplies and the dynamics there?

Devona Slater (07:53):
So you know, the office side of service includes all supplies, all routine supplies that are used to perform a procedure. So those eight codes are included, but what’s not included are the injectable drugs. So the J codes. And so there’s actually in an audit, I adjusted, there was a misunderstanding about how to bill for those J codes when you have single use files. So I may have a vial of 40 detrimental, let’s say, but I only use 30 of it and I have to waste 10. Well, you actually have to document those things separately. 30 milligrams injected 10 wasted in order to bill for the whole 40 vile. And they go on separate line items with modifiers and without getting too specific. Cause I don’t want to, I don’t want to blow your mind, you know, kind of thing, but it is important for physicians to understand that just because they open the vial doesn’t mean we can charge for the whole bile unless they documented appropriately of what is actually used and injected and what is wasted. And that’s really an important key factor for them just to understand that component. So we can bill for all of that drug in getting them the money they deserve for what they’re doing.

Justin (09:19):
That’s I think like a hilarious example for a lay person. From my standpoint, a hilarious example of the mind boggling complexities of medical billing is you need to document what you didn’t inject as well as what you did in a single use vial to be able to bill for the whole file, even though by definition, if it’s single use, the whole thing went somewhere, I guess

Devona Slater (09:42):
I get it, but you’re not, you’re, you’re working with the government, which is not a logical system. So that’s what makes it so interesting.

Justin (09:52):
Curious, you know, just as far as like the tales from the trenches, give us an idea of the magnitude in terms of liability or in terms of financial impact for some of these mistakes that you’ve uncovered, like what you just described, especially, I mean, you take a little mistake and you multiply it by X number of patients per day, times X number of days. And that gets expensive in a hurry.

Devona Slater (10:14):
Oh yeah. Well, in an office setting, it’s not unusual for them to do 20 procedures in a day. They line those epidurals and transfer aminals and the sets up. And so it’s, it’s not unusual for them to do 20 minutes a day. And so if they’re, you know, billing for that though, the danger is, is they probably are using, you know, those single dose files. And they may be injecting 80. They may be injecting 40, I don’t know, but anything that’s not documented and they bill for more of, than they did, the insurance company would come back and make them liable for paying that money back. So let’s say that it’s just 10 milligrams on every dose and it’s a code that actually is built by the milligrams. So, you know, you have 10 on every single one. Now, you know, the money for the drugs is really not the issue because they pay pennies, you know, literally pennies, but it’s the line item problems.

Devona Slater (11:14):
If the insurance company chooses to prosecute it as intentional fraud of billing, what’s not documented that gets them. So that’s 11,000, $12,000 a line item plus triple damages of what you’re doing so well. I, I had never seen a case specifically just on that. It’s usually one of those add on things that, you know, because you’re being investigated for this, we’re going to add on drugs and supplies and we’re going to add on PT and we’re going to add on braces and we’re going to, you know, kind of like we said before, the government never comes for dinner unless they get dessert. And so those kind of extra things are the dessert that are little mistakes that are unintentional, truly. They really aren’t misrepresenting what was used. It’s just that they’re not documenting it. Right.

Justin (12:07):
I find that in practice whether it’s CMS or whatever, the like investigative or enforcement department of the CMS wing is sort of like enacting enforcement here in practice, do they act is that, you know, I understand these numbers are piling and they sound big and scary. Like, Holy cow, we’re going to go bankrupt as a medical practice. Is there some, like if you’re, if there’s an infraction and it’s like your first time, even if it’s like a systematic one that adds up to a big problem, is there some like negotiating or some leniency, or how does that work if you kind of run a foul of the rules,

Devona Slater (12:42):
It kind of actually depends on what the rule is that you’re running a foul with. So unintentional billing mistakes, as long as you come forward and actually work with the government, confess your sins. So, you know, ask for forgiveness. I’ve never seen them really, and, you know, really try to not work with doctors. And a lot of it depends on how good your healthcare attorney to be quite honest and how they approach it. So usually if you come to them and fess up and say, this is what has happened. I recently was involved in a case where the government actually pointed it out. It was in providing anesthesia services in a chronic pain practice. And so the CNA had misbilled his time, basically in those scenarios. And so they were coming back and saying, your times are way off from the averages of what you’re reporting and unbeknownst to him, the billing, he had a third-party billing agency, the billing company actually had picked up, not his anesthesia in time, but his out of recovery room time.

Devona Slater (13:58):
So tremendous 30 minutes, at least on every case, if not more two units or whatever on that. And so that’s kind of how the chronic pain can get pulled into, because that was an investigation regarding anesthesia services in the chronic pain. Then they began to look at medical necessity for these procedures, not only for the anesthesia portion, but even for the LCDs, which are the, the payer policies basically of what tells you what you can do and what you can’t do and what has to be documented. They start looking at that, well, do you have medical necessity to do this epidural or to do this for set? And so one thing just led to another, just switch another and you know, it is kind of a snowball effect. So you want to sure if every piece of your practice that you do. And I think a lot of times in the docs that I see that are very entrepreneurial, they get pulled in to doing starting labs or delivering DME or setting up a pharmacy in their practice. Those are truly separate businesses. And so you have to treat them as such because they, again, cause more risk for you in your own physical practice of the chronic pain, interventional salt. So I think balancing those is always important for a chronic pain practice.

Justin (15:29):
I’m curious with the infraction side of things, obviously CMS is the one that sort of carries the big club, but, but there’s also, obviously you have a payer mix that is comprised of a lot of non CMS payer. So how does that work as far as if there is a mistake or it does, you know, obviously the blue cross blue shield can’t like find you and Sue you, but I’m sure there’s

Devona Slater (15:53):
Yes, they can. Yes they can. So the thing that physicians don’t always realize is all of the payers are kind of in bed with each other on this fraud and abuse kind of thing. And so they share information, whether we’re, we’re not allowed to do that, that would be, you know, Bryce steering and all of these bad things that they tell us. We do. But they’re allowed to share information. So it’s not unusual that a physician might have a problem with UHC and UHC as an investigation. And then lo and behold, three months later, blue cross is investigating you or is investigating you and they all talk whether you want to believe that or not. And so we do see that, you know, the other problem is, is that they have the right to take it to the government too. So you may start it out as a small blue cross audit and nobody thinks too much about it.

Devona Slater (16:52):
And if they suspect fraud and they have the right to go to the OIG and actually turn it in on behalf of the taxpayers and the government, right. And so they then turned that stuff over. And the next thing you know, you have an OIG investigation going up. So w you should never take any payer requests for records or anything lightly. And I always believe in what I call kindergarten proofing those records. So if I’m a physician I’m not sending records back to a payer until I’ve looked at them and I’ve read VLCD that there, that involves that procedure or the practice that I think they may be questioning. And then I take a highlighter and actually color-coded so pink is my medical necessity. Green is my utilization. You know, blue is maybe, you know the diagnosis is that support the reason that physical exam and the reason why I can do it.

Devona Slater (17:54):
So it is what I call kindergarten proof. So that any RN or anybody that’s got any kind of medical background can say, wait, no, he complies specifically. Or she complies specifically with the payor rule. We shouldn’t investigate. And so the more work you do upfront on those kinds of payer analysis, when they’re starting to question and they ask for the den records, the more work you do on those 10 records saves you time in being investigated on 50 records or a hundred records, and your last five years of records. So it really is important to take each one of those document requests. Very, very seriously sounds like an IRS audit, very similar. It is a government agency. It’s the same playbook, I guess. Absolutely. Absolutely.

Justin (18:46):
I’m curious, you know, I sort of postulated to you before this call, like the difference between the physician’s experience of billing in somewhere like a hospital setting versus somebody who has their own office based practice made with the surgery center attached. And I sort of had some ideas about how I thought that would transpire and you kind of corrected me. So maybe describe how a physician, a pain management physician primarily will sort of stay away from the anesthesia for a minute interacts with the billing and coding in different sites of service and, and the significance to that physician of this conversation.

Devona Slater (19:19):
Sure. So in the office setting, we see a lot more of those physicians doing their own billing and probably the danger there is you only know what you know, and they kind of work in a vacuum. And so it’s very important for them to send their staff or get some kind of outside education on an annual basis, or sign on a podcast or do something to keep those individuals updated. The rules change all the time. And so it’s important that they have some way to stay in the know whether it’s through their specialty societies. They do a lot of programs and stuff like that. So that’s one thing that we see if they’re using an outside billing agency for goodness sake, please, and you please do your homework and due diligence about that agency. We have two physician groups that have contacted us in the last month that are under investigation because the billing company is under investigation.

Devona Slater (20:18):
And literally they had no idea how it was being built, just like the RNA that I referred to earlier that was billing. They didn’t realize or didn’t ever do an audit to check on how those billings were really going to the payer. They just knew they were getting paid and lo and behold, you know, the third-party billing company was putting additional diagnosis on or something that they shouldn’t have been doing. And so, you know, again, in compliance as the owner, or, you know, in the compliant and in the board of director kind of role, you have a responsibility to ensure that anyone that you contract with is doing it correctly. So, you know, that is kind of like your insurance policy. So just because you assign it and you say, no third party, you’re in charge, you’re doing the billing. We still have a responsibility to check on that at least annually.

Devona Slater (21:24):
So that’s one of the things that we see sometimes billing companies can get really creative sometimes with what they do. And we want to make sure that that’s not going on with any of the docs. It’s much more likely in a hospital setting that that billing is outsourced. Again, and everybody does have the responsibility of making sure that what’s, they does go under their individual NPI or the national practitioner identification. And so they are liable for what’s being built. And so a lot of times even employed physicians sometimes don’t realize that the claims that they create could result in them losing their license, because it is, would be looked at as intentional fraud. So it’s very important to protect that medical license at all costs and that right, and that we clearly make sure we have something documented to show that we’ve been doing that on an ongoing basis.

Justin (22:26):
This brings up an interesting question. And I’m actually, as you’re describing this, I’m, I’m seeing a lot of sort of similarities in my corner of the world with finance and like your CPA, who does your taxes, which is like for the lay person, doing a lot of things, taking a very complicated internal revenue code. That’s a pavilion pages internalizing it, applying it to your own situation, and then they’re preparing your tax return. And they’re sort of on the hook for it, but you are too. And if your CPA gets in trouble then you’re going to be in trouble. Even if your CPA is preparing your return and you’re trusting them. So assuming that they are in fact, a CPA, which actually gets at my next question of how would you recommend a pain management physician vet, a billing service to the uninitiated? It’s probably pretty tough to tell between outsource solution a and outsource solution B and, you know, you can compare on price, which is like, well, they’re gonna charge, you know, 5% and they’re only going to charge 4%. And there’s obviously some other key variables, but how would you encourage somebody to look under the hood if they’re trying to figure out how to, how to bill for their practice.

Devona Slater (23:31):
So I think a very good question and answer between the physician and their coding supervisor or whatever is the right way to go about that. You know, you can throw out a, about a Fossette block, let’s say that says, Oh, I did the medial nerve branch at L three L four L four five. You know, how would you COBOL and just see if they ask the right questions back, did you block, you know, the upper and lower nerves of each of those joints and those kinds of things to make sure that they do have an understanding of the specialty, same thing with narcotic management. One of the big things that we see is that they don’t add the diagnosis and again, Z 79.891 for narcotic the management of opioids. And that is one of the things that is being tracked and that you want on your claim because it makes it a more complex visit.

Devona Slater (24:35):
And so, you know, not reporting that or not reporting that they have chronic pain on those diagnosis codes, doesn’t help really tell the story, which is what the diagnosis codes are supposed to be. Why does it tell the story of what we’re doing there today? And so they’ll add every code and the kitchen sink. I mean, I’ve seen 12 diagnosis codes go across that that is not what the patient was there for today. They were there to get their meds for their, you know, for their Oxycontin or whatever for their low back pain or for LER to treat their post-laminectomy syndrome. Let’s say. So in that example, you know, it would be a chronic pain that G 89.2, it would be the narcotic management for the opioids and which is the Z 79 eight nine one. And then it would be post-laminectomy syndrome, the M 96.1.

Devona Slater (25:34):
That would actually, that’s what I did today. That’s what we’re doing today. And a lot of billing companies will just put every diagnosis, the physician lists on it, or the physicians are guilty of pulling that stuff forward. And those are really not the diagnosis as they’re treating today. And so that’s really an important part to clean up in your EMR to avoid any confusion. Yes, we know that they have had these other things. You never code signs and symptoms when you have definitive disease. So if I have lumbar DVD, you never put low back pain on there because it’s indicative of the lumber D so things like that, that just kind of help physicians understand the coding nuances of what has to be done. And coders need to take a closer look at what’s really being done in the visit and read the note to make sure that it’s accurately reported to the insurance company.

Justin (26:34):
So everything that you’re saying implies that the physician knows enough about billing and coding, to be able to interpret whatever it is that, that billing manager at this company that they’re vetting is telling them and say yes or no, it doesn’t meet the standard that I have for my practice. Do you find that most physicians are suitably qualified to be able to do that?

Devona Slater (26:56):
If they’re not, they need to be, I would just tell you that it is not it, if you’re going to own your own practice and do it, it is just like in a CPA firm, you know, to say that you don’t know the tax code in the state that you’re working in, not a good idea. And so, you know, it’s, it’s like, you don’t know the policy, the national policy on spinal cord stimulators, wait a minute. Why are you placing them? What are you doing? You know, and I get that. They don’t always get that training, but you know, the manufacturer’s reps, even though you can’t always take what they say verbatim, they usually do have a pretty good job. They’ve done a pretty good job of reimbursement and advising on coding and things like that. That is credible. It always should be vetted against a payer policy because there are still things that are deemed experimental that they’re kind of going a little bit over the edge, but it is important to, you know, to, to actually do your own research, but they can be relied upon in some situations to actually just question or even to know that a billing company can bring something who is their person that does research and how do they go about researching?

Devona Slater (28:12):
You know, the first thing I always do is Google the procedure and see if I can watch it. So I understand the anatomy and the things that are involved in doing it so that I can get to the right code.

Justin (28:26):
Do you find that there are certain practice profiles that tend to do billing a certain way, either in-house or external and are there like break points based on number of providers, number of patients, those types of things, and is there like a, not like a best practice, but what you’ve seen that kind of works in different practices as far as just building the infrastructure for

Devona Slater (28:49):
Right. It’s probably then the midsize pain group is the one that I work with the most. So it’s probably, you know, four or five physicians. They’re a little bigger than your one in one man, you know, office setting, they usually do have some kind of an ASC and kind of a caveat to that is to make sure that your ASC is an absorbing costs, that it shouldn’t, and that you could charge for professionally that and some of the tricks now for the AFC is, you know, the insurance companies are all about bundled pricing. So we just had a provider who’s having trouble with an Aetna situation where Aetna, you know, actually threw it into the ambulatory surgery center that all pathology, radiology and anesthesia is bundled into the ASC payment, but the anesthesia group is outside. They don’t have anything to do with that contract. So, you know and there’s a big fight going on, but it’s not really relevant other than be careful what you contract, make sure you understand what’s in those contracts before you go out, especially when you have related entity where you might own a portion of each of those companies, those things. Yeah. But

Justin (30:11):
Are there any, you know, when you’re, when you’re sort of rolling up your sleeves, you’re walking into a practice you want to help them assess the appropriateness of their coding and if they’re coding for, and if they’re billing for everything they need to be billing for, and just the sort of the revenue cycle, as you know, sort of follows that, are there any key metrics that you’re looking for or any key data points that perhaps somebody listening to the show could say, Oh, I can actually go and try to understand here’s either a couple of things to make sure I look at, or a couple sort of macro level metrics to understand how my billing looks

Devona Slater (30:46):
Well. You know, I think it’s interesting. And when I go to a practice, I kind of look at it. I try to kind of present myself as a secret shopper, so to speak, you know, a little bit and understanding kind of how I’m greeted at the front desk, whether they asked me for insurance cards, I’ve listened to sit in the lobby and listen to those conversations, whether they ask for those payments upfront. So probably a key metrics would be how much of that money are you collecting upfront? And are you continuing to serve patients that have opened balances and not asking for those balances, shame on you? You know, and so really that front desk person, where they tend to be probably the lowest paid individual in a practice, they really should be one of the higher paid ones because they’re responsible for a, your presentation to the public and be collecting the money.

Devona Slater (31:40):
You know, you have a perfect face to face opportunity to get a credit card, to get a check at that time, to be able to do that. And there is a skill and asking for money, and it’s not like Mrs. Smith, you have a balance. It’s how would you pay your balance today? How would you like to pay your balance today? It’s all in how you frame that up. And so probably time at you know, at time of service, how much money is being collected is one metric. I would look at specifically for a group. The other one is how long it takes from the time I do the procedure or the visit to get that claim out the door and to the insurance company. That’s a very good metric and it should be within three days, you know, which means that we’ve got to do our documentation and sign those charts and get them official.

Devona Slater (32:31):
So we can actually do that billing. So that’s always a, sometimes a problem is physicians will not get their charts signed or, and there might be a backlog. And so billing doesn’t feel like they can release them until the charts are signed, or they might not drop into a queue until the charts are signed. So that’s another metric that we always look at to see if we have, you know, an underlying illness, so to speak, you know, and then what you’re getting paid on those gross charges. Does it fall in line with your contracts? You know, right now charges are really tally marks, you know, because we have so much of the managed care coming back. And if you don’t have a system that loads what you’re expecting to get back and checking that against each one and running basically an exception report of who’s not paying you that amount and why shame on you, you know, you really have to check on, you know it’s, it’s that same trust, but verify and you know, to trust the insurance company to pay you correctly, it’s fine.

Devona Slater (33:38):
You should be able to do that, but you always should be verifying that they are doing it, especially if you’re doing multiple level procedures or let’s say that patients on Plavix and you have to take them off. So maybe you’re going to do a joint injection in their knee, as well as that lumbar epidural in their back, because they’re off the Plavix. So, you know, again, making sure that got coded right, to go to the payer to indicate why we’re doing multiple procedures, because they do not like that. The payers really don’t like that. And a lot of times they won’t pay for it. So again, having that flagged in their billing and doing, and then we look at gross gross collection rates, net collection rates, and bad debt is another one that is important for paying practices that we don’t get too many.

Devona Slater (34:30):
There there’s no shortage of paying, you know, people in pain of, of patients. The problem is there’s a shortage of good pain pain. And so we want to make sure we get our fair share so that we can stay in business. So really understanding that part and relating that back to scheduling so that we always have an open appointment for the managed care that pays us, you know, 60, 70% of bill versus the Medicaid patient that pays us, you know, 5 cents on the dollar, you know, kind of thing. And we don’t like to do economic type of scheduling, but in this environment, it’s almost, you know, to limit how many Medicaid slots you have open. Not that you don’t take Medicaid, but they might have to wait two days to get in to see you instead of the same day or something.

Justin (35:21):
What does a healthy net collections rate and maybe describe what that is.

Devona Slater (35:25):
Okay. So net collections means that it is everything that you could have collected under contract. So you have to make the adjustments for those contractual write-offs, which is the difference between, you know, your gross charge versus that. And, you know, I’ll be honest in a pain practice that’s down in the 20%, it’s probably 28%. You know it may be as high as 32, but a lot of times, because they have set their charges at three times Medicare or something like that. And so many of the payers now tied to the Medicare fee schedule for the chronic pain procedures and services. It’s not unusual to see that 33% number or 28% number for that kind of deal for net co. I mean, for gross collections, net would take those adjustments off. So you’d expect 90% of what could be collected, collected. And again, high deductible plans have eroded that a little bit, HSA, HSHS things like that. And so it is important to understand that the benefits of your individual person, we have often recommended, and especially in a practice that owns an ASC and has some other components, is that they really do financial counseling with the patient right up front before the procedure is ever done. This is the expectation, this is where you’re at on your deductible. You’re going to need to bring $200, $300 with you because we know that that’s going to be at least your liability and what you’re doing.

Justin (37:08):
I’m just thinking through sort of the skillset required to be able to do that on the fly while you’re doing other things in the office. That sounds not straight. Yeah.

Devona Slater (37:15):
Yeah. It would take a seasoned billing person to really get it right. And somebody who has some communications skills specifically, because you don’t want to appear greedy or unnecessarily, but you do want to be helpful. And so I kind of look at it as, you know, this is the insurance that you have patient Mrs. Smith or whatever. And let me help you get the benefits that you’re entitled to under your policy and approach it in that way. Instead of saying your copays $800, you need to write me a check. So again, it’s all about posturing and how you actually do it. You get a lot more flies with honey than you do vinegar, right? And so so we want to make sure that that person representing our practice in that financial counseling level is a honey person

Justin (38:06):
And HR and staffing is so critical if you’re gonna scale any organization, once it’s beyond just you. And that’s certainly way outside of the med school and residency curriculum.

Devona Slater (38:16):
Absolutely. And it is like the most important, again, every person needs to understand it is everyone’s responsibility to collect the money. So many times I’ll actually sit and just observe and I’ll have, you know, an ma or somebody say, Oh, don’t worry about, or don’t do it. And I’m like, are you kidding me? You know, you gotta be crazy. You know everybody in the practice is responsible to collect the money

Justin (38:45):
And you could make an argument that there’s a, there’s a disconnect between the leadership and the, you know, the, in that ma for example, in that, in that instance, like that ma isn’t connecting practice revenue with their job,

Devona Slater (38:58):
Correct. That is it. And I will tell you, the person that should not be talking about finances is the physician. And, you know, we, because they tend to be so empathetic and God love them. I want to just hug all of my pain docs because they’re so compassionate and they’re such good people and they really do want to help them and they don’t want to do it. And they, every time they talk about money, they give it away. So we want you to actually delegate that to somebody that’s got a financial background, you know, and is protective of you. It’s kind of like your mother again, you know, I look at it and I said, I used to tell my, the physicians that I worked for, I mean, the very beginning of my practice, you be in charge of caring, compassion, I’ll be in charge of greed. You know, I’ll make sure we all get paid and you make sure that you, you know, are, are caring and compassion because they just don’t always work well together.

Justin (39:54):
That makes perfect sense. And I wouldn’t have thought of that necessarily if I was, yeah, it’s not necessarily intuitive, but it’s, it’s, I can see how immensely valuable that is. And even this little nugget, like, I hope if people have listened, you know, 40 minutes into this conversation about billing

Devona Slater (40:10):
And are asleep divide and conquer when it comes to absolutely.

Justin (40:15):
And being the, you know, the voice of care and compassion to just use like a broad-brush stereotype and then having the business savvy person at the front desk or a practice manager, or somebody just have also compassionate, but honest and Frank.

Devona Slater (40:30):
Sure. And again, how I’m helping you get your benefits, how, because this is coverage, you pay for patients, you know, it’s not anything I’ve signed up for. So how can I help you get your benefits correctly? And again, it’s that mindset of how we do things like that. That really does make a big difference.

Justin (40:53):
In the minutes we have remaining here, I’d love to talk briefly about the ENM code changes. So one of the things we’ve talked about in the past is like, Oh man, anesthesia has been, reimbursement’s been going down, down, down from CMS that isn’t true across the board for everything, especially in the pain space with the ENM codes. So talk a little bit about some of the changes for 2021 and sort of the, the rationale there.

Devona Slater (41:17):
Sure. So a big curve in the road, first change in over 20 years to the evaluation and management, and now they have set it up so that you’re paid either by the time that you spend in doing those or the medical decisions that you make. And the medical decision-making process still has the three components. But they’ve been defined a little differently and it’s been a little bit streamlined so that history of present illness and counting all the review of systems and counting the physical exam, while you still have to do those, it’s not going to to relate directly to your level that you’re doing. So that’s a big change do an appropriate exam. That’s all you need to do. You don’t have to listen to their heart and look at their pupils and do all of that other stuff.

Devona Slater (42:11):
There’s no GPU or GI exam that’s necessary. And vain real is realistically for, you know, the average pain patient on mat, but understanding what is appropriate for that visit and just documenting that is what they’re trying to get to. You know, it is like the government, hi, I’m here to help you. You should always be a little bit wary of it because they never make it simple. This was supposed to streamline and make it simpler, but it’s got some clouds lurking. One of the good things is as almost all of the audits that I’ve done since the first of the year on evaluation and management really have brought the coding up. So don’t be afraid if most of your levels are coming in at a nine nine two one four, based on the complexity of the product of the problems they’re seeing, usually a pain patient has multiple pain problems.

Devona Slater (43:07):
And what you’re dealing with in doing that usually does do that. I think that there were a couple of definitions that I would point out one being chronic is the AMA defined chronic as being one year or greater in pain. Traditionally it’s been three months or greater. So calling it’s important to get in your note when that problem started and how long you’ve been dealing with it, to make sure that it’s clear to the coder, that it is a chronic problem, and then the number of problems. So back me, neck, all of the different problems, headaches that you’re dealing with, you want to make sure that is clearly denoted in your note. And then the other one is the definition of stable physicians have never really thought about that to them. That means, you know, that we’re not having any, you know, majority, you know, they’re stable, they’re not dying or anything that’s.

Devona Slater (44:08):
But stable in the AMA new definition means that they have not met their treatment goals will rarely do we see in the history of present illness or in the tear plan, those treatment goals spelled out and how they’re doing in achieving those treatment goals. So one of the things we’ve been trying to help physicians do is to say, Mrs. Smith’s treatment goal is to have her pain score at a two. She continues to function, but at a level eight, our goal is to bring it down to that level too. So making sure that, you know, unstable quote is supported even though in a physician’s eyes, she may be very stable on her medications, but she still is not functioning at the level. We want her to function. So those are two caveats kind of that way. Again, we do see that the code levels are increased.

Devona Slater (45:04):
So that’s increased payment to the group. I think that there will be some revisions. We, we saw the first ones mid-March come out from the AMA and CMS clarifying, you know, what prescription drug management means. You can’t just write the script. You have to actually do kind of in pain management, what we refer to as the six A’s. So you have to, you know, assess their activities, list a level of analgesia, talk about barren behavior maybe their mood and affect of how they’re doing any adverse side effects that they’re having from the medication and adjunct therapies. So are they doing exercise, PT, walking every day? All of those things, if you address that in the context of how they’re using their medication, you will qualify for that prescription management, which is a level four decision-making. So yeah, two or more chronic problems, even if they’re stable, that would qualify, you ended up higher moderate level of risk.

Devona Slater (46:13):
And then you’re doing narcotic management with those things detailed. That gets you a level four, regardless of the number of data elements you have to review, which we would always review the, the national or the state practitioners, prescription monitoring service. Again, I think one of the things that physicians maybe don’t know or understand is if you can bill for a test, you’re not allowed to count it. So if you order a UDT and you’re doing that, or a urine drug test, I should say, or screen in your office, and you’re billing for that because you have a physician lab you’re not allowed to count it as an element in those. So thinking about it, you know, you can count outside x-rays when you order them, but when they review, they expect when you order them that you will review them. So you can only count them one, two, so little caveats like that, but overall it’s a win for the chronic pain physician really? Is.

Justin (47:18):
Are there any other, either common, common pitfalls that you’ve run into recently or new changes that you think that people should be aware of? I think there is a push right now

Devona Slater (47:30):
By CMS to nationalize the LCDs and the billing policies. We saw it come across originally emphasis injections, and there’s now floating around one for epidurals. So I think that there is a push to quote standardized, but that means that for many physicians they’re going to have greater scrutiny. So I would tell you that medical necessity, having those rules and knowing how to look those rules up and making sure at least once a year, if somebody prints out the LCD policy, highlights the requirements in documentation that have to be included in the note and then make sure that your note actually cues you into or asks you the question, how much increase in mobility has the patient had? Did I do a physical exam Fossette loading exam? Did they get greater than 80% relief? I mean, to help them remind them to document these things and the notes going through that would be the biggest takeaway I think in today’s environment is to make sure at least once a year, somebody annually prints that LCD or NCD out.

Devona Slater (48:45):
And actually then cross-reference it to your EMR procedure notes and the supporting evaluation of management that supports why we’re going to do that procedure, the note before to make sure we’ve got everything documented that we have to, because the things that I see right now in the audits is it’s easy for the government to trip you up, basically on little tiny things that, of course they’ve got this, why would we proceed with this kind of invasive procedure if they wouldn’t have failed all of these kinds of things, but yet in our notes, we don’t ever reference failing physical therapy or failing, you know, the other adjunct kinds of things, prescription management, things like that, to be able to do it. So that would be my one real takeaway that I think every physician should do.

Justin (49:37):
Got it. Makes perfect sense. Well, let’s wrap it up there, Devona. Thank you very much for your time. And thanks for joining us today on APM success. My pleasure take care. If you liked what you heard this week, head on over to APM success.com, where you can find more content and free resources to help you build a successful career in anesthesia and pain management. If you want it to leave a review in iTunes, that also really appreciate it. Thanks for using some of your valuable time to join me today on APM success.

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