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that setting up a fully operational practice that receives reimbursement on every case is not a fast process. “I think it’s really im- portant for administration to tell them that setting up your own practice is very time consuming. It can take six to nine months to establish new provider numbers.” Mowles continues, “If you’re a new
provider, what do you have to tell pay- ers? Do you have quality studies? Do you have a treatment plan you stick by? It’s going to be really hard to do a valid pro forma because it’s next to impos- sible until you already have established a name, a tax ID number and an address to say to any payer, ‘How are you go- ing to pay me for supplies?’ ‘How much will you pay me for sedation?’ and ‘How much are you going to pay me for inject- ed drugs?’ You can’t open discussions before you have something to discuss. These physicians are not going to get paid for quite some time, so hopefully they have a line of credit to sustain them for at least a year.” It is also worth reminding them that this will be their own practice—their own business—and they will have to take on the responsibilities of running the facility, Mowles says. “You are accountable,” she says.
“You are the licensed individual who owns this practice. You better start open- ing your own mail so you know what’s happening with your business. You bet- ter understand your insurance contracts, you better understand how much you are spending on everything and you really better understand human resources. “What’s also important here is that
they have to be realistic about their reve- nue potential,” Mowles continues. “Rev- enue has to be viewed in context of risk and hours input. How hard do you want to work for how much money? These guys that want to go off on their own, do they have what it takes to be self-em- ployed? Not everybody does. Nobody is going to hand them a paycheck.” According to Ramirez, another ef- fective technique ASC managers can use
22 ASC FOCUS MARCH 2013 Learn More
A recording of the webinar “How to Keep Pain Management Cases in Your ASC” by Amy Mowles, chief executive officer and president of Mowles Medical Practice Management LLC, is available from ASCA. To order, go to
www.ascassociation.org/ RecordedWebinars.
to educate physicians who are consider- ing leaving the ASC, besides discussing all of the requirements of performing these procedures in their office, is to put together a pro forma for the physicians showing them what they would earn if they performed these procedures in an office setting versus an ASC. “Do the work, show the numbers,
show the physicians the difference,” she says. “Don’t just make general state- ments about it. It’s very expensive from a return on capital perspective to operate an office-based pain program. If the phy- sicians own enough of the ASC, they’re definitely going to be better off finan- cially in the ASC than putting significant cost into this initiative where they may make a few hundred dollars more per procedure versus having ownership in a successful ASC.”
Single-Specialty: Not an Easy Choice In some instances, pain physicians might consider leaving a multi-specialty ASC and opening their own single-specialty surgery center. “You could certainly lose those pro- viders to developing their own single- specialty ASC, but you can protect your facility from losing all of the patients,” Mowles says. “I would want an iron-clad contract in a multi-specialty ASC that says the physicians can’t go off and build their own single-specialty ASC within a certain, albeit reasonable, mile radius.” If physicians are considering opening such a facility, the administrator is still
in a position to point out that many of the challenges facing physicians setting up an office-based pain program also ap- ply to physicians establishing their own ASC, suggests Mowles. “It doesn’t matter, in the eyes of
those who have jurisdiction, whether you are removing a mole from some- one’s nose, doing a lumbar epidural injection or doing a full-blown laminec- tomy,” Mowles says. “If you want to be paid as a single-specialty pain manage- ment ASC, you are going to be building exactly what the regulations tell you to build, whether you think you need it or not. It’s going to be costly, it’s going to be time-consuming and it’s going to be a significant challenge, no matter how you look at it.”
Payer Position on Pain Another possible scenario that Thiel says could one day lead to the migra- tion of pain procedures out of ASCs is if the Centers for Medicare & Medicaid Services (CMS) and commercial payers were to change their position on where pain procedures can be performed. “If a pain procedure or interventional pain procedure drops from favor from the CMS list of ASC-approved proce- dures, obviously there won’t be reim- bursement for the case,” she says. For now, this doesn’t appear to be an issue of great concern, says Mowles. “Medicare even added the least invasive procedures to the ASC payment list, so clearly, they see where their own en- rollees belong.” ASC leaders, however, must never take this for granted and need to continue to work on a number of fronts to help ensure pain procedures remain on the list and in surgery cen- ters, Thiel says. “We do a lot of proactive work with CMS officials to help them understand the importance of retaining the interven- tional pain procedures on that list,” she says. “I think probably one of our great- est opponents to this is the hospital lob- byists. I don’t think the hospitals like the
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