Billing and RCM for Pain Management and Personal Injury Physicians: The Essential Guide
Provide care with confidence you’ll be paid
As in all specialties, billing and RCM for pain & PI physicians has its quirks and idiosyncrasies. But your billing service should ensure you don’t have to worry about that.
In pain management & personal injury medicine, as in any type of practice, billing and revenue cycle management is essentially a complex accounting process, with many quirks and idiosyncrasies. In our experience, most physicians, in all areas of practice, underestimate what is required to navigate this process successfully.
As a pain & PI practitioner, issues of medical billing and RCM may not be top-of-mind. You’re providing vital care to improve your patients’ lives. Getting paid is not necessarily your primary focus, and it doesn’t need to be. Rather, you need skilled people on your team who are tasked with collecting what you’re owed.
In the areas of billing and RCM, every specialty is a little bit different. In our experience with our pain and PI medical billing clients, the following issues are most common.
Adopt the Appropriate Business Mindset
You are a highly skilled practitioner, and you deserve to be paid for your services.
This might sound obvious, but many physicians struggle with this aspect of medicine. Many, many highly-skilled, good-hearted practitioners simply let billing & RCM fall through the cracks. We know several pain & PI physicians who, before they became our clients, were losing thousands of dollars per day due to billing issues! They knew they had problems, but as we said, their primary concern is caring for patients, not billing and getting paid.
For such clients, the first thing we address is mindset. Your practice is a business, and you must get paid. If you were running a charity, this wouldn’t be such a concern. But you’re probably not running a charity, and thus the business aspect of medicine demands that you address billing and RCM issues with the same level of diligence you apply to your clinical practice.
Equipped with this business mindset, you’re ready to begin addressing your practice’s RCM challenges.
Understand the Steps of RCM in Specialty Practice
In pain & PI practice, as in other specialties, patient encounters follow a predetermined sequence, and each step is dependent on the ones that precede it. You’re certainly familiar with this sequence from a clinical perspective, but we’re going to look at it from the perspective of billing & RCM. In order for you to get paid, your biller must fulfill and document each step, in the right sequence, at the right moment in time.
Here’s how it goes:
Step 1: Obtain referral from primary care provider
The vast majority of patients today have their healthcare coverage through an HMO. When a patient has chronic pain, their first step will be to visit their primary care provider. Once a PCP determines that their pain or injury requires specialized attention, they refer the patient to you, so you can book the appointment for further evaluation of the patient’s pain and injury.
In terms of billing the HMO, referral from the patient’s PCP is required as the first step of the billing process. Your biller needs to document and track the referral. Every subsequent step of the billing process depends on those that precede it.
The referral is the first point at which the concept of “medical necessity” becomes relevant. The PCP initiates the referral after determining that whatever medication or other medical advice he or she has provided is insufficient to address the patient’s pain and injuries. Demonstration of “medical necessity” is key at
Step 2: Initial appointment & evaluation of patient
Once the patient comes in for their appointment, you can determine what type of care is required, if any. Perhaps you’ll recommend a procedure, such as an epidural steroid injection, a nerve block, a facet joint injection, or something similar. Perhaps a stronger medication will be sufficient, and no procedure will be immediately necessary.
If after the initial evaluation, you determine additional intervention or medication is appropriate, you will of course document your evaluation and recommended course of treatment in your EHR.
Your biller must now fulfill several new tasks:
Deliver your EHR notes to the patient’s insurance provider
Ensure your recommendations are within the parameters of “medical necessity” as determined by the patient’s insurance
Obtain an authorization or approval from the patient’s insurance to cover your recommended course of treatment
From your perspective as a physician, all of this occurs in the background, as you proceed with treating and caring for your patient. In our experience, most physicians will proceed with treatment on the assumption that their biller has everything in order, and that they will be paid.
From a clinical perspective, treating the patient ASAP is clearly preferable, but from a business perspective, there is a risk of not getting paid if your biller makes any mistakes.
Step 3: Determining Medical necessity
In theory, it would seem like the “medical necessity” of care should be exclusively, or at least primarily, determined by the physician. In reality, however, the patient’s insurance company has an independent process for evaluating the medical necessity of each course of treatment.
From the insurance company’s perspective, a claim of medical necessity usually rests on a number of different criteria, such as:
The patient having insurance for at least a minimum period of time
The patient experiencing their health issue for a minimum period of time
The patient’s health issue being the result of an underlying condition
The physician having attempted other interventions, which have not resolved the patient’s issue thus far
The above are some examples, and there may be others, depending on the specific course of treatment for each specific patient.
In terms of demonstrating and documenting “medical necessity,” the key takeaway is that your clinical notes must specifically fulfill all of the insurance company’s criteria for approving that specific course of treatment. On the insurance company’s side, an auditor, rather than a physician, is most likely responsible for making these evaluations of medical necessity, although physicians will certainly be involved in setting the parameters for such evaluations.
Step 4: Demonstrating and Documenting Medical Necessity in your Clinical Notes
If the patient’s insurance company reviews your notes, and for some reason determines that your recommended course of treatment doesn’t meet their criteria for “medical necessity,” your claim will be rejected. In many cases, you may have already done the procedure before you learn the claim has been rejected.
In our experience, many rejected claims are related to issues with the clinical notes from the initial evaluation. Different insurance companies have different requirements related to information that must be included in the note in order to demonstrate medical necessity. By itself, this might seem confusing, but what’s more, these requirements may change at any time. In practical terms, it’s nearly impossible for even the best billers to keep up with changing requirements of individual insurance companies.
Nevertheless, a good billing process can ensure you get paid despite these complex and often convoluted requirements. Your should work with your biller to ensure the following:
Use robust global templates in your EHR notes, to ensure you include all required information and meet necessary criteria
If a claim is rejected, your biller should immediately contact the insurance company to determine the specific reason for the rejection
Your biller should ensure you make edits and updates to your clinical notes ASAP, so the claim can be rebilled
Once you understand the insurance company’s new requirements, should update the global template in your EHR to include any necessary information
In practice, you can update your notes and rebill each claim as many times as necessary. However, each rejection causes a delay in payment, and requires more work from you and your team, so you should strive for efficiency.
Step 5: Performing the Procedure and Course of Treatment
From a clinical perspective, it’s extremely important that billing issues don’t hinder you from providing care. From the time you first evaluate a new patient, you should be free to follow the best course of treatment you possibly can.
For example, when you evaluate a patient who is in severe pain, and determine that an epidural steroid injection is medically necessary, you should be fully empowered to perform that procedure at the earliest possible time. However, it must be noted that this involves a significant up-front expense on your part, for both the medication and operation of equipment.
Your biller must ensure that the demands and urgency of providing care do not conflict with the necessity of getting paid for this care. You should never find yourself wondering whether you’ll be paid for a procedure or course of treatment. If the patient is covered, you should be able to proceed with full confidence that the billing process will be managed successfully. If for some reason the patient is not covered, you must be made aware of this in advance, so you can choose the best course of action.
Step 6: Waiting for Claims to be Paid
If your billing service is doing its job, you should receive payment within a predictable time frame.
What does this mean exactly?
As much as possible, you should try to quantify the effectiveness of your billing process. Some key reports to review include:
If your billing service is doing its job effectively, these numbers will reflect it.
The Role of an Effective Billing Service
A good medical billing service should eliminate, or at least drastically reduce, any conflict between providing clinical care and billing for that care.
In our experience, many physicians, across all specialties, often perform procedures without full confidence that they’ll be paid. This is perhaps more common among pain management and personal injury doctors, due to the nature of this area of medicine. Patients often come to you in severe, debilitating pain. For most physicians, the urgency and humanitarian necessity of providing relief from pain often outweighs any concerns about payment. From a humanitarian perspective, this is understandable, but from a business perspective it is unsustainable.
Furthermore, it’s unfair for physicians to bear the financial burden of such care, when insurance providers are responsible for covering the patient’s health expenses. A skilled and diligent biller will ensure that, when you see patients with proper insurance coverage, you never have to wonder whether you’ll get paid.
If you have questions about your current billing situation, we offer a free, no-obligations revenue analysis to help you better understand your revenue and collections. Get in touch with us to learn more: