Tuesday, June 9, 2015

Updating Patient Insurance Information, Post By: Kay Ouellette, Billing Manager

Many people don’t realize how important giving the correct insurance information at the time of service is.  It can create great headaches for the Practice and the patient.  When the Office does not have the correct information and a claim is billed to the wrong insurance company it starts a chain reaction, which ultimately ends up to the patient’s responsibility.

Let’s start at the top:
-     Patient checks in at the window and does not update the sheet for any patient changes and marks same. 

-      Provider sees the patient and a claim is created. 

-      Billing looks over the claim to see whether the claim needs special attention according to the insurance company such as a needed authorization attached, medical notes, or accident date on the claim. (this really depends on each insurance company, example Medicare, Wcomp, auto, or commercial insurance all have different requirements.) The biller is assuming the claim is correct due to do patient update, so at this point the Provider has spent the time to see the patient, the biller has taken time to review the claim or charges and file the claim. 

-     The claim is sent to the insurance company. The insurance company can take anywhere from 30-45 days to process the claim and sometimes much longer, only to receive a denial for the claim stating it has rejected, because the patient does not have coverage at the time of service.

-     Now the provider has to work the denial and try to research if it denied in error or not.  Upon researching the claim the patient didn’t have this insurance at time of service and then the balance gets transferred to patient responsibility. 

-    The patient’s receives a bill and is not happy. 

Needless to say there is a lot of time, effort, and resources to bill an insurance company and if you have several patients a day that do not give the correct insurance update then there is a lot of time and money that is lost.
We at Central Florida Pain Management are very grateful for all who on conscious of their current insurance and make an effort to update it.   Thank you.

Post By:
Kay Ouellette, CPC
Billing Manager

Prior Authorization, Post By: Teresa McPherson, CEO

In today’s world of so many insurances to choose from and not really knowing which one is the right plan for your care can be confusing when it comes to choosing a plan.  Some insurances plans such as HMO’s may require a prior authorization for any services to be rendered.  I would like to take a few minutes and help our current and potential patients understand what a prior authorization is:

Pre-authorization is a term used for obtaining prior approval from your insurance before having a procedure or service done.  We here at Central Florida Pain Management try to make sure we obtain authorization that is needed prior to services being rendered so you can receive services that are needed for your care.

Insurance Denial and Appeals
Sometimes even with a prior authorization on file a provider can still receive a denial for services that have already been rendered to the patient.  A denial means that the insurance company has decided not to pay for the procedure or other service that your doctor recommended or preformed due to many reasons such as the insurances own medical necessity guidelines which may not be met (yes, that’s correct your insurance can decide what services are acceptable over your own doctors recommendations) based on the procedure to be performed, related diagnosis code and how many times the patients may have already received this type of service already .  There are even some still pre-existing policies out there as well.  We here at Central Florida Pain Management strive to try and make sure that any services that require a pre-authorization are obtained and meet your insurances guidelines.  However even the most diligent providers office can still be denied payment for some services.  Sometimes the provider can appeal with a letter and medical documentation to convince the insurance company to change their decision and provide coverage for the service.   However in some cases if the provider is participating with the insurance plan and the appeal is denied the provider does not receive any reimbursement for the services that were provided to the patient.  It is not only important for your doctor’s office to understand your insurance plan and what it will and will not cover but it’s also just as important that the patient understands what plans/polices they are choosing to sign up with.  Only with both parties informed can the doctor and patient make the right decisions together for any future care.

Post By:  Teresa McPherson, CEO

Friday, February 20, 2015

Pain Practioners

Pain practitioners are pulled in many directions.

-First our obligation  is to care for our patients TO THE BEST OF OUR ABLITY, give them a medically sound and scientific  treatment. Unfortunately pain is closely linked to emotions. Plus a significant amount of medications for pain relief also stimulate our pleasure, gratification and addictive centers. This generates a secondary effect on the patients using opioid pain medications. Their pleasure/addictive centers get stimulated by the opioids creating a craving for more. This makes the situation difficult because patients are blurred into using more and more opioids, in the name of  still having PAIN.  It has only been recently that we have been able to clearly understand this conflict unfortunately at the expense of having created many iatrogenic (medical) addicts.

-Then, we are monitored by the DEA (drug enforcement administration) with rules and regulations that we prescribers HAVE to follow.  An important group of our available pain medications (opioids) are not only very powerful in diminishing pain but also very addictive and craved by users, so needles to say very lucrative in the black market. This creates a tense environment between prescribers and their pain patients.

-Also insurance companies are directly targeting pain practices. They are cutting re-imbursement for needed procedures, visits, tests and refusing to pay for a lot of the safer medications that we consider more effective and appropriate.

 Multiple “masters” to try and please. No winners, just losers creating a lot of tension between us (doctors) and our patients. The gap between us has gotten wider, and full of roadblocks and  conflict generating demands.
Post By: Cesar A. Euribe, M.D.

Thursday, February 19, 2015

Pain Doctors Reputation, By Cesar A. Euribe, MD


In the practice of Pain Management we encounter multiple roadblocks.

Our patients come from a variety of backgrounds and most suffer with difficult situations and chronic pain.

Pain providers also come from many different backgrounds and styles of practice. Over the last few years there has been an influx of so called pain management specialists who joined the field with NO formal training, experience or understanding of the core of the pain management discipline.  Unfortunately some of the self proclaimed specialists were only equiped with their pens, prescription pads and a DEA license.

Pain practitioners are pulled in many directions.  I will talk more about this soon.

Cesar A. Euribe, MD

Monday, January 12, 2015

Alternative Therapies - By Cesar Euribe

I came across a patient who asked me if he postpone his traditional injections and pain management to try and see if the use of TART CHERRY JUICE would help his back and leg pain. He had heard from one of his friends who has a hip problem that his pain was gone by using that juice..

After my bruised ego stopped wining, I was able to look into that situation and was surprised by the explanations on-line.

“It’s the ANTIOXIDANTS stupid!!! In my tantrum, I forgot that there is a high content of multiple “good things” in our fruits and vegetables. Sometimes we forget that most medications come from the plants in our wonderful world. They provide us with the wonderful products we know now are essential for a balance feeling of well-being. We directly get co-enzymes, vitamins, antioxidants, prostaglandins steroids, hormones or their most important precursors.

Our grandmother’s were so right when they demanded we eat all our fruits, veggies, cod oil, spices etc etc. Those have been the basis of true homeostasis. Other OTC medicines like chondroitin, calcium pyruvate, magnesium etc are also in fruits and veggies.

My education has been in the traditional western medicine, I have been educated in some of the finest medical centers of the world such as MGH, BCH, Judge Baker, UPCH hospital and a few others. Finest traditional scientific medicine but it now feels at the expense of other disciplines now known as Alternative, Holistic, Eastern, Homeopathic, therapies.

In the last 10 years and because of high demand from the patients we are paying more attention to such alternative therapies.

I will elaborate more on Alternatives in future blogs.

Post By:
Cesar A. Euribe, M.D.