8 Best Practices for Establishing and Improving Pain Management in Your ASC

Pain management can be a successful specialty for ASCs looking to add or enhance this line of revenue to their centers. According to the VMG Health's 2009 Intellimarker, around 17 percent of surgery centers' total case volume was due to pain management. However, there are some challenges and nuances specific to the specialty of which administrators, physicians and staff members should be aware.

In this article, several experts discuss eight best practices for integrating and developing a successful pain management program into your ASC.

1. Efficiency is key.
Surgery centers pride themselves on their ability to provide surgical services at a more efficient rate than in the hospital setting. However, pain management requires all areas of the center working at its optimal level.

"Pain management is a high-volume specialty with physicians seeing one patient every 15 minutes," says Joyce Deno, COO of the Eastern Region for Regent Surgical Health. "As a result, it often takes much longer for patients to recover from procedures than the procedure itself, which can lead to back logs in the recovery area. Administrators need to recognize how this differs from other specialties, and they should have a highly efficient PACU staff that can quickly and safely assess patients and move them."

Scott Glaser, MD, of the Pain Specialists of Greater Chicago in Burr Ridge, Ill., also notes that teamwork is essential to running a successful pain management program in an ASC. "Physicians should sit down with all involved parties and develop protocols and systems in order to help the process," he says.

This point is extremely important when it comes to physicians' expectations versus anesthesiologists' expectations when it comes to the type of anesthesia to be administered.

Fernando Gruta, administrator of Hinsdale (Ill.) Surgical Center, says that his ASC made this error when first starting its pain management program. "We had a disconnect between the surgeons and the anesthesiologists."

Another complicating factor to overall efficiency of pain management procedures is physical space. Since patients will spend more time in the recovery area than in surgery, surgery centers must prepare for the additional patients in the PACU.

Mr. Gruta says that his center hired an outside company to assess the surgery center's waiting room space. "We had to rearrange the furniture to accommodate the increased volume," he says.

Ms. Deno agrees that physical space constraints are an important consideration when adding pain management to your center. "Minimize what is necessary, and prepare to have three pre-op bays and three recovery bays ready per procedure room," she says.

2. Reimbursement for pain procedures requires accurate documentation. Due to the nature of pain management and its procedures, payors often require meticulous documentation. Workers' compensation and motor vehicle accident (MVA) cases are part of the reason payors request more detailed information, but fraud and abuse also add to payors' scrutiny of pain management procedures.

Dr. Glaser, who is an active member of the American Society of Interventional Pain Physicians, mentions the efforts interventional pain physicians have made in order to preserve coverage for some pain procedures under Medicare and private insurers. "Pain management reimbursements from Medicare have been under attack, mainly because there has been some fraud and abuse surrounding facet joint injections, in particular. Although not a complete victory, Medicare will cover the procedure; however, marry carriers have imposed local coverage determinations, or LCDs, which limit the amount of injections a patient can have in one year," he says. "In fact, just recently Noridian, which is a Medicare carrier for nine states, was going to eliminate coverage for facet procedures. We were able to salvage a reasonable LCD through the efforts of ASIPP and our CEO, Dr. Laxmaiah Manchikanti."

Due to these limitations and strict rules on pain management procedures, careful documentation is required prior to and after a patient's procedure at the ASC. Physicians first need to indicate the medical necessity of procedure, and ASCs need to verify coverage with the insurance company prior to the procedure, according to Ms. Deno.

Ms. Deno also notes that workers' compensation and MVA cases require a lot of review. "Don't just receive information from the physician's office and assume it is okay," she says. "Make sure to validate the information. Otherwise, it could result in delayed payments for both the ASC and the physician, and be sure to communicate this to the physician's office to eliminate errors and delays in the future."

Failing to verify insurance can lead to the ASC losing a significant amount of revenue, depending on the pain management procedure, according to Ms. Deno. For example, with MVA cases, a settlement often results in a certain amount of money dedicated to the patient's healthcare. ASCs should check to ensure that money is still available prior to the procedure. "If a center doesn't get paid for an injection, the center may be out only $50 or $60, but for something more complex, like a radiofrequency procedure, the center could lose $200," she says. "That is why centers should make sure funds are left to cover the procedure."

Mr. Gruta says that many insurers are requiring more documentation for pain management cases. "It's subjective, and many insurers are making it harder to get pre-certification. It's an arduous process, and ASCs should be ready for the difficulty," he says.

3. Maintain excellent communication between the physician's office and the ASC. Because pain management procedures treat chronic conditions, many physicians will schedule procedures on the same day or the day before patients arrive at the surgery center. For ASCs, this can be troublesome.

"Even though pain procedures aren't surgery per se, ASCs still need to treat patients as though they were full surgical patients," says Ms. Deno. "ASCs need to send them the information required by the new Conditions for Coverage in the time frame designated."

For this reason, it is important for ASCs to inform physicians' offices that procedures require at least 24 hours notice before patients come into the center and that calling in at 3 p.m. the day before with a list of new patients for the physician's block time is not sufficient.

Ms. Deno also notes that last-minute cancellations are also inherent in pain management cases. "Often these are chronic pain patients that are not used to schedules [due to long-term injury or unemployment], so we see a lot of non-compliance," she says. "This can be hard to manage in a multispecialty ASC because we need to send notifications, adhere to schedules, etc."

4. Make sure pain physicians are certified and dedicated to the ASC and pain management.
Many ASCs begin their pain management programs by allowing their anesthesiologists to perform procedures in the afternoons, when the center is slow. However, many argue that in order to have a truly successful program, pain physicians using the ASC should be dedicated solely to the practice of pain management.

Dr. Glaser says, "There are national guidelines and interventional treatment algorithms that pain physicians should be aware of in order to best treat patients. The algorithms help the physician to determine the pain generators and pathways (whether pain is caused by a disc, facet, or sacroiliac joint or joints) which then help guide future treatment (facet joint injection vs. a medial branch nerve block vs. radiofrequency lesioning). If a physician isn't dedicated solely to pain, he or she may not be aware of these algorithms which may lead to under or over treatment, ineffective treatment or inappropriate treatment."

Interventional pain management has also been recognized as its own specialty by Medicare which has led to more appropriate practice expense information and reimbursement. There are multiple certifications available for pain management but not for interventional pain management. Dr. Glaser suggests that ASCs attempt to ensure that their physicians are truly specialists in the field and certified by the American Board of Interventional Pain Physicians or by the World Institute of Pain as a Fellow of Interventional Pain Practice. This is, in part, to safeguard the ASC against abuse and fraud related to pain procedures.

A pain management physician on staff who understands what is going on in the industry can be a great asset to the ASC, according to Mr. Gruta. "It helps when the physicians understand what is going on, what procedures are covered and what aren't, which keeps us informed so we know what is going on in the specialty," he says.

Ms. Deno also suggests talking with prospective physicians prior to their arriving at the surgery center to discuss expectations and benefits of the ASC. "Help them to see the ASC as an extension of their office that can help them to manage patients. Know your costs, how many procedures are required to break even and your capacity. Know what you can offer to the physicians and present it to them," she says.

5. Remember that pain management patients are repeat customers. Unlike many patients that come to ASCs, pain management patients are typically going to return to your center. As a result, ASC staff should continue to have a strong focus on customer service.

"Patients do notice how they are treated when they come to the ASC and this should force ASCs to provide a higher level of care," says Dr. Glaser.

Reinforcing a culture that is customer-service oriented is one way to ensure a good experience for pain management patients, according to Mr. Gruta. "If you keep an environment that is customer friendly, it will help not only your pain management service, but also your bottom line," he says.

6. Prepare for a significant start-up investment. Some of the equipment required for pain management can mean a significant capital investment for your ASC, depending on what procedures you chose to perform. Here are some of the recommended pieces of equipment (price ranges included when known):

  • C-arm (preferably with 180° rotation) — ~$140,000
  • Pain management table — ~$50,000
  • Fluoroscope — $75,000-$200,000
  • Fluoroscope bed — $5,000-$15,000
  • Radiofrequency needles/equipment — $10,000-$50,000
  • Anesthesia cart
  • Syringes and needles

Mr. Gruta estimates the startup costs for his ASC's pain management equipment to be between $250,000 and $300,000.

Physical wear and tear on the facility itself may also factor into some of these costs, according to Ms. Deno. "Moving that many people in such a short amount of time will affect the waiting room, pre- and post-op areas and your staff," she says.

7. Schedule pain management on days that can handle a high-volume specialty. Running two high-volume specialties on the same day can be difficult for an ASC, so it is important for centers to schedule pain management on days when other high-volume specialties are not operating at the ASC when first starting out.

"You need to find the right balance," Mr. Gruta says. "Your clinical staff needs to be prepared for volume and speed."

8. New procedures may provide opportunities for ASCs. Most ASCs with pain management currently perform epidural injections, radiofrequency procedures, IDETs and facet joint injections. Adding just one newer procedure can potentially be profitable for ASCs, as long as insurers will cover the procedure.

Some ASCs perform installations of trial pain stimulators, which deliver low vibrations to a patient's lower spine to treat back pain, and leads for the devices. This procedure is the step before a patient receives a permanent device, which can currently only be installed in a hospital setting.

Mr. Gruta and Ms. Deno note that if insurers do not cover the leads for these devices, ASCs can be out nearly $15,000, so it is critical that ASCs first determine whether payors will reimburse them for new procedures before adding them.

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