TMS financial questions

[esob]

I'm a psychiatry-matched MS4 currently on a pain clinic elective. I am giving a presentation about some RCTs of TMS for chronic pain conditions and would like to include some basics about reimbursements for TMS in general. I'm aware that it's not currently billable for pain (except migraines), but the goal is to provide some background about the reimbursement landscape for approved conditions.

I've scoured some old threads and found the following info thus far:

• 2022 thread:
  • Attending #1 (academic setting)
    • Dept of VA uses Fairhealth’s metrics for total RVU’s for TMS
      • CPT 90857 = 8.31
        • Initial session
      • CPT 90868 = 6.22
        • Subsequent sessions
      • CPT 90869 = 8.67
        • Subsequent session w/ remapping
          • $1000 by one major insurer
  • Attending #2
    • Intake wRVU = 2
    • f/u wRVU = 1.5
• 2023 thread:
  • Northstar rep stated that a practice needs 2-3 pts per day to cover ROI in 1st year, then 1 per day in subsequent yrs
• 2012 thread: Reimbursements anywhere from $184 to $400 per session. 20-30 sessions are considered a full course. Cash price for entire treatment course $8k-$12k

A few specific questions that I have:

1. Do these numbers look like they are in the ballpark for what you currently see?
2. Do the machines have some sort of use fee (like uro lasers or PRK machines where you pay a fee per use in addition to initial equipment costs).
3. Any anecdotal accounts of pts treated for an approved condition that also had some comorbid chronic pain condition where the reported to you that the pain condition was better after TMS.

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[clozareal]

It's 90867 for initial. I haven't seen RVU numbers for TMS. The price seems high but it may include facility fees or a negotiated rate.

TMS machines vary by device company. Magventure is a flat rate plus yearly fee for warranty, but you also need to pay for each cap and coil wear. The return on investment is probably around 3 patients per day for an average of $250 per session for the first year and then 1-2 per day in subsequent years so you're probably right on that. NeuroStar you lease the device and pay per session. The cash price I've seen is $10-15k for one course.

 

[esob]

It's 90867 for initial. I haven't seen RVU numbers for TMS. The price seems high but it may include facility fees or a negotiated rate.

TMS machines vary by device company. Magventure is a flat rate plus yearly fee for warranty, but you also need to pay for each cap and coil wear. The return on investment is probably around 3 patients per day for an average of $250 per session for the first year and then 1-2 per day in subsequent years so you're probably right on that. NeuroStar you lease the device and pay per session. The cash price I've seen is $10-15k for one course.

Thanks for this, I'm doing the presentation today. I figured there would be more to it than simply the cost of the machines.

 

[nexus73]

what are the benefits of an expensive machine vs cheaper machines?

 

[clozareal]

what are the benefits of an expensive machine vs cheaper machines?

marketing

 

[randomdoc1]

what are the benefits of an expensive machine vs cheaper machines?

I think there is one head to head study showing H coil has some better response rates than figure of 8. Also, H coil is much more user friendly and easier to train techs. Which saves me tons of valuable time. It’s much more expensive but has not been hard for me to still profit. Now my device is paid off and all I pay annually is a service fee for any maintenance needed so profit margin is even higher.

 

[psych_0]

I think there is one head to head study showing H coil has some better response rates than figure of 8. Also, H coil is much more user friendly and easier to train techs. Which saves me tons of valuable time. It’s much more expensive but has not been hard for me to still profit. Now my device is paid off and all I pay annually is a service fee for any maintenance needed so profit margin is even higher.

How much do you get reimbursed for each treatment session (initial vs follow-up)? Have you found that only certain insurances are worth your time with TMS? I almost made a new post but I saw this was just posted in April. Trying to decide if it's worth my time because there are at least 2 clinics in the surrounding 20 miles offering it.

 

[psych_0]

It's 90867 for initial. I haven't seen RVU numbers for TMS. The price seems high but it may include facility fees or a negotiated rate.

TMS machines vary by device company. Magventure is a flat rate plus yearly fee for warranty, but you also need to pay for each cap and coil wear. The return on investment is probably around 3 patients per day for an average of $250 per session for the first year and then 1-2 per day in subsequent years so you're probably right on that. NeuroStar you lease the device and pay per session. The cash price I've seen is $10-15k for one course.

Do you mean that the insurance is reimbursing $250 per session? Or is that only with certain insurances?

With regards to the cash price, how does that work? Patient pays completely out of pocket and doc provides the superbill for patient to work out themselves with the insurance company? I imagine that would be harder to find clients given that most people accept insurance for TMS, or is that not the case?

 

[randomdoc1]

How much do you get reimbursed for each treatment session (initial vs follow-up)? Have you found that only certain insurances are worth your time with TMS? I almost made a new post but I saw this was just posted in April. Trying to decide if it's worth my time because there are at least 2 clinics in the surrounding 20 miles offering it.

Anywhere from $158-$400 per 90868 in my area. The trick though really is outcompeting the others. You could get a great fee schedule but it don't mean squat if you don't attract enough traffic. It's tough competition. Although I'm glad to say my own clinic is sitting nice and pretty LOL. Marketed as a sweet local mom and pop shop with personalized and evidence based care. Not some McDonald's in and out BS.

 

[clozareal]

Do you mean that the insurance is reimbursing $250 per session? Or is that only with certain insurances?

With regards to the cash price, how does that work? Patient pays completely out of pocket and doc provides the superbill for patient to work out themselves with the insurance company? I imagine that would be harder to find clients given that most people accept insurance for TMS, or is that not the case?

It's a payor mix.

Yes. They would be billed to pay out of pocket and try to submit for reimbursement from insurance. It will be harder to find patients who can afford it.

 

[psych_0]

It's a payor mix.

Yes. They would be billed to pay out of pocket and try to submit for reimbursement from insurance. It will be harder to find patients who can afford it.

Sorry, I don't understand what you mean by payor mix? Still kinda learning the lingo of the outpatient world.

 

[clozareal]

Sorry, I don't understand what you mean by payor mix? Still kinda learning the lingo of the outpatient world.

It means the average rates of all the different insurances that you take. It's the lingo of all healthcare finances, not just outpatient.

 

[randomdoc1]

Actually, if you are in network, easy to bill insurance directly and have them pay you directly. But be sure to check what pt deductible or copay is. You can lose a lot of money on high deductible plans because patient still has to pay a lot if they did not meet their deductible yet. Best seasons for TMS are Q3 and Q4. If you do not contract with insurance, competition is harsh. Because many TMS clinics do. And even as an in network provider, competition is still very active.