1. Getting started. When you receive the payor’s proposed contract, including the entire proposed fee schedule, be aware that just about everything in there is negotiable.
- You can start by requesting an increase in all fees.
- The vast majority of pain management procedures fall into one to three categories. If the payor is objecting to the entire increase, try to focus on a few specific issues, such as two or three group rates that are significantly low and are your most frequently billed codes.
- Using objective data to back up your points will always give you a stronger case.Data sources may include:
- Your practice’s accountant or reports you run on average billed procedures and average number of procedures per patient encounter.
- AMA Annual Socioeconomic Survey
- MGMA publications
- Medical Economics Survey
- Department of Commerce Web site
- Be sure to identify all payor policies that could undermine your practice. Watch for requirements that do not agree with requirements of other payors. Multiple or conflicting rules will wear down your billing staff. A contract is going to create more work if it requires invoices while other contracts do not, or if it reimburses for multiple procedures at 100/50/50 when others reimburse at 100/50/25.
- Consider using a “requesting a standard” addendum for all your contracts. This addendum typically lists the fee schedule, and how multiple procedures, implants and supplies will be paid. Identifying these items in the contract will help you build leverage, create a good political base and record successful agreements.
2. Negotiating grouper payments. Many payors still base ASC reimbursements on the old “grouper” methodology, which Medicare phased out in calendar year 2008.
- Payors that use the old groupers often add a tenth grouper, Group 0, which typically includes minor, office-based procedures such as trigger point injections and non-fluoroscopic guided procedures (nerve blocks) and sometimes even off-list procedures that are not in the payor’s regular list, such as discography. Carefully check rates for this added group because they may include procedures you perform (or plan to) and could be undervalued.
- Add-on codes such as those for each additional level (facets joint injections, transforaminal epidural injections and neurolytics) should all have the same “mapping” — assigning them to the same group — as in other contracts. Otherwise, you will find discrepancies when you perform a cost-to-reimbursement analysis. Moreover, some payments may turn out to be below Medicare rates, which is hardly a good idea.
- Find out the payment methodology for off-list procedures. These are referred to as “no Medicare value” or “non-grouped procedures.” This is vitally important for both the old groupers system as well as the new APCs. The old grouper payment system had a significant number of procedures that were off-list, many of which were typically office-based procedures without fluoroscopy guidance. However, discography (CPT 62290 and 62291), a popular diagnostic pain management procedure, was and still is off-list.
- It is critical to ascertain the payment amount and methodology. You may find that requesting mapping to a specific payment group is better than a percentage of billed charges. Payment arrangements based on a percentage of billed charges typically carries a default amount, called a ceiling, which may not be cost effective.
- Find out how implantable devices are handled. Devices such as spinal cord electrodes and stimulators and drug infusion pumps may be carved out and billed separately, or the price of the implanted device may be added to the group. If devices are carved out, make sure the margin is above the current Medicare rate.
- Placing electrode arrays for a spinal cord stimulator trial (CPT 63650) is a popular procedure and Medicare’s current reimbursement is actually quite good. Remember that Medicare’s payment indicator of H8 means the procedure is not subject to multiple-procedure discounting. Since many pain management physicians place two-electrode arrays, make sure the payor won’t reduce the payment of the second placement, whether or not the device is included in the reimbursement.
3. Dealing with plans using the new APC methodology. Commercial payors are increasingly transitioning from groupers to the new ambulatory payment methodology system developed for Medicare.
- For APCs, ask whether the payor’s mapping is precisely the same as Medicare’s. If it is different, your procedures may turn out to pay less than you expected.
- How are off-list procedures such as discography paid? These should be defined with a default rate at a percentage of billed charges, with or without a ceiling. If there is a ceiling, make certain your fee is high enough for the discount. The other option would be to suggest the payor add these off-list procedures to a particular group.
- Ask about additional carve-outs for drugs, supplies or fluoroscopy you would like to have. It doesn’t hurt to ask how these will be reimbursed rather than if they will be.
- With APCs, it’s better to negotiate the all-inclusive rate or negotiate an amount for the device plus a reasonable handling fee. You do not want to have a contract that forces you to send a paper claim with an invoice.
4. If the payor offers both methodologies. Determine your top 15 most frequently billed codes. You may actually be better off with the calendar year 2007rates and groupers, especially if you have a lot of minor procedures and the default rate for off-list procedures is favorable.
5. Negotiating any kind of contract. Here are some basic tips that will apply to any kind of payment system you negotiate.
- For procedures requiring a costly one-time use device, such as a spinal wand for percutaneous discectomy (62287), which costs about $1,000 per case, ask if its pass-through code (C2614) would be carved out. This is important because the payor may have grouped this with a rate that does not cover the costs of the one-time use device.
- Inquire about the new CPT codes for facet joint injections. Prior to 2010, these injections were billed with two CPT codes, one code for the first level and another for each additional level. But under the new 2010 codes, these injections are billed as three codes: single, second and third, plus each additional injection. If the reimbursement is the same as last year, try to make sure facet injections for the third and additional levels (64492 & 64495) get a higher fee.
- Ask for the payment policies and rates for multiple procedures during the same patient encounter. If you don’t settle this, you could end up with a contract that pays below Medicare rates. You should get 100 percent of the fee schedule for the first procedure and then 50 percent for each additional procedure. You do not want to let it go down to 25 percent for any further additional procedures after the second. Ask if there is a maximum number of procedures allowed per patient encounter. This is not the same as medical necessity precedence.
- Agreeing to an all-inclusive case rate is not a good idea for most pain management procedures, unless the rate is high enough to cover multiple pain procedures involving bilateral and/or additional levels injections. Make sure this does not somehow include the professional component of a fluoroscopy.
- Ask for additional payment for the technical component of the use of the C-arm for fluoroscopy guidance and interpretive reports. The most frequently billed codes as follows:
- 77002-tc Fluoroscopic guidance for needle placement for spinal injection procedures
- 77003-tc Fluoroscopic guidance for needle placement for nerve blocks
- 72275-tc (Epidurogram (with dictation) w/o use 76005)
- 72285-tc (Radiological interpretation, cervical)
- 72295-tc (Radiological interpretation, lumbar)
6. Final tips. Remember to read the entire contract and assess all the ways it could impact you now and in the future before you sign.
- If you can’t reach a reasonable agreement, ask yourself: Would losing this contract benefit or hurt my practice? How much of a market presence does this payor have? And do we see a significant amount of this payor’s enrollees?
- It’s essential that the contract is a friendly, mutually beneficial agreement. You have a lot of mutual interests. For example, what benefits the plan’s enrollees benefits your patients. And if the contract is cumbersome for you to administer, it will probably be cumbersome for the payor as well. Remember to work closely with your payor representative. People respond positively to people they know and respect.
Contact Amy Mowles at amy@mowles.com.
The information provided should be utilized for educational purposes only. Facilities are ultimately responsible for verifying the reporting policies of individual commercial and MAC/FI carriers prior to claim submissions.
