Welcome to our Pain Management Program. The following is a list of "guidelines" and general information about the Pain Program. Read them carefully, as they will prevent misunderstandings. These guidelines have been instituted base on experiences and events that have occurred in the past. They are designed for your safety and that of others.
A great deal of time and effort has been spent on producing all of this information. Read and study all of the information carefully. Not reading and studying the provided information will be interpreted as lacking interest in getting better. The same holds true for not taking time to adequately and accurately answer the provided pain questionnaires.
On the average, we will not do any type of nerve block procedure on your first visit. Your initial visit is an evaluation only.
Make sure that you are given enough medication by your physician to last until the next time that you see him/her, and not just until you see us. We will not prescribe any medications on your first visit, in fact, being seen in the clinics does not automatically guarantee that you will be taken as a patient. We will accept your case only if we believe that we can help you.
Patients are seen by appointment only. Regular business hours are Monday through Thursday, 8:00 a.m. to 4:00 p.m., and Fridays from 8:00 a.m. to 12:00 noon. There will be no walk-ins. Patients coming in without an appointment will not be seen.
Should you not keep a scheduled appointment, there will be a charge for failure to notify us in “sufficient time” to fill that time slot. (“Sufficient time” is considered to be more than 24 hrs.) In addition, should you not be able to keep three consecutive appointments, you will be automatically discharged from our program. If you are unable to keep your appointment, or are going to be late, please call our office as soon as possible. This courtesy allows us to be of service to other patients. Our telephone number is (336) 538-7180.
Should you be late to your appointment, you will be rescheduled. You should check with the receptionist 10-15 minutes prior to your scheduled appointment. Should you fail to check with the receptionist 10-15 minutes prior to your appointment, you may have to be rescheduled.
Please be prepared to stay for several hours on the morning or afternoon of your appointment. Your treatment here may involve referral to other specialists, such as medical psychology, physical therapy, and other medical consultants. If needed, these appointments will be scheduled at the end of your visit.
A certain amount of waiting time may be unavoidable; therefore, you may wish to bring some reading material (or other) to pass the waiting time as pleasantly as possible. Do not make any other appointments or compromises on the day of your visits to the clinic. Due to the limited amount of waiting room space, please do not bring more than one person with you if possible.
Occasionally, our schedule may be cancelled due to weather problems, such as hurricanes or snow storms. You may check to see if the office will be open by calling 336-538-7180 or 866-543-5398 (toll-free). In addition you may check the local news. On the average, we will follow the lead of the Kernodle Clinic at Alamance Regional Hospital. Nevertheless, we recommend that you call the above numbers, were there should be a recording giving you further instructions. Please check the above numbers, since there may be occasions when the Kernodle Clinic may remain open and we do not.
Rescheduling your cancelled appointment - It is your responsibility to make sure that you obtain a new appointment. Call the above numbers and leave a message requesting rescheduling.
We do not believe in pain or disease management over the phone. Because of this, we would like to avoid phone calls as much as possible. Any questions or concerns about your management or your condition should be addressed during your regular appointments. Phone calls should be made only for emergencies. (Please see the section on “Emergencies” for a clear definition of what an emergency is.)
You may be billed for your phone call. If a physician talks to you on the phone, you will be billed for the call. Since the call will have to be documented (dictated, transcribed and filed), it caries an expense, which also includes physician time. Because most insurance companies do not cover this expense, you will be personally responsible for this charge. Please ask your physician for phone call rates.
During regular business hours, the Pain Center staff will be committed to the treatment and service of patients in the facility. Phone calls will be returned at the end of the day, in the order in which they were received. No phone calls will be returned until the end of the day. Please avoid multiple phone calls, they will not speed up the return of your call. In fact, they tend to slow it down since every time you call, your chart will be taken out of the order in which it was received, to add the new message and then placed back at the end of the stack. (Example: Your 1st call was at 8:43 AM, and the 2nd call was at 3:52 PM. You were the 1st and last call of the day. Between those two, there were 52 other calls. Rather than been the 1st call to be returned, now you will be the last since your chart had to be removed from its initial 1st place, to have the 3:52 PM message added to it. Now, upon been returned to the stack, it occupies the number 52 position.)
We will not to discuss case matters over the phone. If you have had a recent study done and there is no evidence of a significant problem, we will discuss the results upon your return to your next appointment. In the event that the results of the test suggest that there may be an urgency, or emergency, we will contact you as soon as possible. Make sure that we always have a way of getting a hold of you. If you have any questions about your care or any planned procedures, please contact our receptionist and schedule an appointment to come in and have them answered. We will be more than glad to answer all of your questions, but we will not do it over the phone since it leads to very poor documentation.
Our “Patient Confidentiality Policy” prohibits us from providing any of your medical information to anybody, including family members, without your consent. We will not answer any family member’s questions over the phone. If any members of your family want information about your condition, treatment, or test results, they will need to accompany you to your appointments, at which time, with your permission, we’ll be more than happy to answer all of their questions.
For requesting appointments or appointment changes, please call (336) 538-7180 and ask to speak to the receptionist or the person in charge of scheduling. Please do not discuss scheduling details with the physician(s). It is the responsibility of the supporting staff to help you with these matters.
For questions regarding your bills, account, or any financial aspect of your care, please call our billing offices at (803) 808-8070. Please do not discuss the financial aspects of your care with the physician(s). It is important for them to be allowed to practice medicine and provide patient care.
By definition, there are no emergencies in chronic pain management. If you have a new pain (Acute Pain), or a change in your usual chronic pain, this will have to be evaluated by your Primary Care Physician (PCP), or your nearest Emergency Room (ER). From time to time, you will have flare-ups (worsening) of your usual pain. This does not constitute an emergency. If you wish, you can request an earlier appointment, or to be added to our "cancellation/waiting list", in an attempt to be seen earlier. For the most part, you should attempt to identify what brought up the exacerbation, and during your next appointment, an attempt should be made at coming up with a plan on what to do for those occasions. Walking into the clinic without an appointment, and demanding to be seen is disruptive, inappropriate, and unacceptable, and may lead to dismissal from our program.
Acceptable emergencies are:
1. Problems after a procedure: Prolonged bleeding; redness and swelling around the procedure site; fever; prolonged weakness or numbness (more than 4 to 6 hours after the procedure); shortness of breath; difficulty breathing; paralysis; being too sleepy; disorientation; urinary or fecal incontinence of new onset (Bowel or Bladder Problems), etc.
2.
Problems
after starting a new medication: Allergic reactions; difficulty breathing;
rash; swelling; severe nausea and vomiting; disorientation; severe sedation or
being too sleepy; etc. (You should immediately stop the medication)
In both instances, you should first go to the nearest Emergency Room (ER), and then have the physician there give us a call. Other physician calls are the only type that we will immediately attend to.
Running out of medications is not an emergency! Please read the next section.
1. No phone refills. No medications will be called-in. No prescriptions will be faxed. No medications will be changed over the phone. No new medications will be started over the phone. The only way that you will be able to get your medications will be by keeping your appointments.
2. Refills of all medications should be requested during your regular appointment. It is your responsibility to know how much medicine you have left, and whether or not you will need refills before your next appointment. Prescriptions will be provided only during your appointments. If you forget your refills, you may not have enough medication to last until your next appointment. Remember that should you get home and realize that you did not get your prescriptions, we will not be calling them in. You will need to get another appointment just to get those medicines. Save yourself some trouble, and do not leave without getting your prescriptions.
3. No prescriptions or refills are given after normal business hours, nights, holidays, or weekends. We consider it the responsibility of each patient to plan ahead enough such that medications do not run out at night or during weekends. Your physician should provide you with his out-of-town schedule. Make sure you have sufficient medication to last until his return.
4. Medications should be taken only as directed. Taking less than prescribed is acceptable, especially if you do not need as much to get the desired effect, or if you have problems and side effects with the prescribed dose. Nevertheless, the opposite is not true. You should never take more than prescribed, especially without the physician's expressed consent. This consent can only be obtained from your physician during a regularly scheduled appointment. Calling the clinics to obtain this consent over the phone is unacceptable and not recommended. Should you take more medication than prescribed will lead to running out of medication early. There will be no early refills.
5. Patients should preferably bring all of their medications, or at the very least, a complete list of all medications being taken, to each appointment.
6. Always bring your medications to the appointment. Pills may be counted in order to assess your use of those medications. We may also send the medication out to be analyzed for proper identification. Should you not bring your medications, have less than what you are suppose to, or the identification of the medication prove that the medication is not what you were suppose to have, you will be automatically discharged from our program.
7. Getting narcotics from more than one physician is called "Doctor Shopping" and it is illegal in the state of North Carolina.
8. You should never borrow medications from anybody else. This is unwise and dangerous.
9. You should never give, lend, or sell any of your medication to anybody. It is unwise, dangerous, and illegal. We have seen cases of fatalities due to this practice. In the case of a fatality, you will be personally liable and held accountable for the other person's death.
10. Whenever you are given a new medication, always check with your pharmacist to see if there may be any drug interactions with any of the other medications that you are currently taking. Remember that over-the-counter medications and herbs can also interact with prescription drugs.
11. We will not prescribe, continue to write, or renew any prescriptions for medications that you may be receiving for non-pain related reasons (blood pressure medicines, diabetes medications, asthma medication, nicotine patches, etc.).
12. No "nerve medicines". If you have problems with your "nerves" (anxiety, depression, nervousness, panic attacks, suicidal ideations, etc.) you need to see a psychologist or a psychiatrist for help. We will not prescribe things like Valium, Ativan, Xanax, or any other medicine for your "nerves".
13. Lost or stolen medications will not be replaced. We do not accept police reports as evidence of medications been stolen. Lost prescriptions will not be replaced.
14. Please take the time to carefully read the section on "PAIN PROGRAM MEDICATION POLICY".
For those patients undergoing a procedure, please remember not to eat or drink at least (6) hours before your appointment. If you are a diabetic, do not take your insulin or your oral hypoglycemics (blood sugar medicine) until you have had something to eat, after the procedure. Make sure to tell the nurses that you are a diabetic so that your case can be done early in the morning, allowing you to eat and take your medicines as soon as possible. Your other medicines may be taken with a sip of water, on the morning of your procedure. Family members are not allowed in rooms during procedures. Also, it is required that you have someone drive you home after the procedure. The driver most be a responsible adult. Having a Taxi does not meet our safety standards. The person accompanying you should be strong enough to help you, in the event that your legs become temporarily weak, due to the local anesthetics.
Should you eat, drink, or not have a driver, your procedure will be rescheduled. You should always ask your physician to explain the procedure and its risks, before the day of the actual procedure. The staff should be able to provide you with written information about the procedure, before you have it done. If you have any doubts about the proposed procedure, we highly recommend that you do not have it done until all of these doubts have been properly addressed. Nevertheless, remember that because the physician has to work on a previously set time-schedule, properly addressing the issue on the day of the procedure may consume the allowed time scheduled for that visit, requiring that the procedure be rescheduled for a later date.
Blood thinners should be stopped prior to the procedure, especially if the proposed procedure is close to the spine. Prolonged bleeding can lead to hematomas, which can compress vital structures such as the spinal cord, resulting in permanent nerve damage, including paralysis. You should not take aspirin or aspirin containing medication for at least eleven (11) days prior to a procedure. This includes baby aspirins (81 mg). Coumadin, Heparin, Ticlid, Lovenox, and other blood thinners will also need to be stopped. For your own safety, you should consult the physician who prescribed the blood thinner, to assess the risks of stopping these medications, even for a short period of time.
If you have an active infection or a Cold, call and reschedule your appointment. Most of the procedures that we perform, involve the use of steroids. Steroids will temporarily decrease your immune system defenses, leading to worsening of existing infections. (ie.: a simple "cold" can develop into a "life-threatening" pneumonia.)
If there is any chance of you being pregnant, you need to let us know. Some of the medications used may cause birth defects. In addition, some of the procedures that we perform may involve the use of fluoroscopy (x-rays), which may also cause birth defects.
We will not be your Primary Care Physicians (PCP). You are required to have a Primary Care Physician (Family Medicine Doctor, Internist). It is a requirement of our program that you always keep a primary care physician and keep us informed of who this is. We are Chronic Pain Specialists, and this will be the extent of our involvement. All of your other medical conditions will need to be managed by your medical doctor. We will also not prescribe any medications, other than those directly related to your pain management. Please do not ask your pain physician to refill any medicines, other than those prescribed for your pain.
DMV Handicapped Parking Sticker forms will only be signed for patients in wheelchairs. Remember that there is a limited amount of parking spaces available. When you occupy one of those spaces, you are taking it away from someone who may be wheelchair-bound do to paralysis.
"Disability" is a legal term. It refers to what you can do with your "Impairment". As physicians we are not allowed to provide "Disability Ratings". This is a function of a court of law. As physicians we are only allowed to provide "Impairment Ratings", which is a medical determination. Impairment rating refers to the percentage of body surface area and range of motion that has been affected by a particular condition or disease. As such, it is always very low. Essentially, the American Medical Association (AMA) has established very specific guidelines relating to this matter. According to these guidelines, a patient in an intensive care unit, whose life is been maintained by a mechanical ventilator, has an impairment rating of close to 75%. These determinations always tend to spark controversy either with the patient or the insurance companies, almost invariably leading to legal disputes in a court of law. Because we do not have the desire or inclination to get involved in this, a decision has been made to stay away from this type of determinations.
Please do not request any of our pain physicians to fill any "Disability Forms". We do not do disability determinations, work restrictions, return to work determinations, disability ratings, impairment ratings, or continuing disability reports, assessments, determinations, or forms. If any of the above is needed, we can refer you to a physical or occupational therapist for a Functional Capacity Evaluation, with possible impairment ratings. Insurance disability forms will need to be completed by your primary care physician's staff. If such paperwork has to be filled by us, there will be an additional charge prior to the form being filled. Please allow two (2) weeks for completion. No "rush" requests will be done.
In order to override the six-prescription limit, the form states that the added medication should be intended for treatment of a "life-threatening" condition. Pain is not considered a life-threatening condition. Therefore, pain medication does not fit into this category. Hence, your pain medication should be included in the initial six prescriptions, for which no explanation is required. The override should then be requested for the more important medications, such as blood pressure medicine, or blood sugar medicines. The override should therefore be requested from the physician prescribing those particular medications. Please do not request for this form to be filled by your pain physician.
Please do not request these types of determinations from your pain physician. These are best addressed by a physical therapist, after having thoroughly evaluated your capabilities.
These excuses can be provided only for the day spent in your appointments or for short recovery periods, after your pain procedures. Certainly no retroactive or long-term excuses will be given. If you think that you cannot perform your job, then speak to your employer about the possibility of temporary disability. If after treatment has started, you are still concerned about your ability to work, start thinking about contacting your employer for guidance on how to obtain permanent disability.
This is not a psychiatry-based program. Any patients with history of severe depression, suicidal attempts and/or ideations, will be required to be followed by a psychiatrist. Failure to maintain psychiatrist care will result in dismissal from the program. Patients with such medical conditions may be asked to have their pain medications prescribed by their psychiatrist. We can assist the psychiatrist with recommendations, but we will not take the responsibility of providing the patients with potentially lethal medications. Any patients having attempted suicide during the course of our pain program will immediately have all medications stopped, and their care transferred to a psychiatry-base program (Duke University).
Studies have shown that for chronic pain patients that have been out of work for a year or longer, the possibility of going back to their jobs is less than 15%. The same studies have shown that the longer the patient stays out of work, the less of a chance that they will go back. Although we would like to be able to help everybody eliminate their pain, the truth is that most people with chronic pain will continue to have some degree of pain for the rest of their lives. Remember that there are certain conditions that cannot be cured or eliminated, for example: arthritic degeneration. In fact, the rule of thumb is that if you have had pain for longer than a year, chances are that your pain may have become permanent. Our job is to help you manage your pain. Most of the time we can decrease it to the point where it is bearable, nevertheless, it may be unrealistic to think that we may be able to completely get rid of it.
Unfortunately, because of the nature of what we deal with, most of our patients tend to be depressed, frustrated, distrust the system, suspicious, and demanding. Some tend to be aggressive and threatening. In the past we have encountered patients that tend to forget that 100% of the patients that we see are here because of pain that may be as bad or worse than theirs is. In fact, we also treat cancer pain patients, whose life expectancy may be very short, and their pain severe. These patients, due to their short life span, do have priority. We are here to help, and we will do everything possible to do so. Rude, abusive, aggressive, and/or threatening behavior will not be tolerated and it will lead to discharge from the program.
Pain is a subjective complaint. It cannot be seen, touched, or measured. We depend solely on the patient's account of the pain in order to keep track of it. Since everybody tolerates different degrees of pain, the best basis of comparison is the patient itself. To achieve this, we use a pain scale called NAS-11 (Numeric Analog Scale from 0 to 10 [11 characters]), where "0 = No Pain", and "10 = the worst possible pain that you can even imagine" (i.e. something like been eaten alive by a shark). You will be asked to rate your pain on every visit, as well as multiple times before and after a procedure. Please be as accurate as possible, remember that medical decisions will be based on your responses. Please do not try to emphasize your pain by giving us a number above the upper limits of the scale (i.e. ě15î). This will actually be interpreted as "symptom magnification" (exaggeration), as well as lack of understanding with regards to the scale. To put this into perspective, when you tell us that your pain is at a 10 (ten), you are essentially saying that you are at a level of pain where there is nothing else that anybody can do to inflict any more pain on you. (Carefully think about that.)
In the specialty of "Pain Management", contrary to other medical specialties, the responsibility of the patient's care lies mostly on the patient rather than the physician. Patients are expected to make every effort in understanding their condition as well as their treatment. It is the patient's responsibility to ask questions when something is not understood. It is also the patient's responsibility to follow all of the clinic's rules, as well as state and federal laws pertaining to controlled substances. You should always know the names of the medicines that you are taking, the doses, the schedule, the amount left, and how long it will be before you run out of medicine. Patients should have a list of their medicines with the above information, readily available. Always check your prescriptions before you leave, after each appointment.
By now, it should be obvious that we believe in providing as much information as possible to our patients. In an effort to do this, we have this information available in the clinic, as well as via the Internet. For more information, please log on to our Website: www.ncpainmanagement.com
1. Be on time. Always try to be in the office, at least 15 minutes prior to your appointment.
2. Read all the information provided to you.
3. Write down all of your questions, including all of the points that you want to address with your physician.
4. Carefully and truthfully answer the pain questionnaires.
5. Bring all of your medications.
6. Always bring a list of all of your current medications, doses, schedule, and the names of the prescribing physicians.
7. Make sure your referring physician has sent all of your pertinent information to us.
8. Bring the reports on any MRI, CT, or Nerve Conduction Tests you have had done in the past. (At least in the past 2 years). List when and where you had those studies done. Make sure we have this, at least for your second visit.
9. For your second visit, bring a list of all of the medications that you have tried in the past. It will save us time if we don't have to repeat any. Also list any side effects or complications that you have had to those medicines, and why is it that you no longer take them.
10. For your second visit, bring a list of all physicians that have been involved in your care. Whenever possible, include their address and telephone numbers.
11. If your insurance requires appointment pre-approval, make sure that you have it before coming in.
12. Bring your insurance card to every visit. If you have more than one insurance, bring them all.
13. Always bring your co-pay.
14. Bring your driver's license.
15. Bring the following insurance information:
a. Subscribers name and date of birth.
b. ID and Group number
c. The complete insurance billing address
d. The insurance company's telephone number and contact person
e. The subscriber's employer
f. The patient's relationship to the subscriber
16. If you are a Worker's Compensation / Auto liability, please bring the following information:
a. Date of the accident
b. Date that you were last able to work. (If applicable)
c. What is the working diagnosis for the claim?
d. Patient's claim number
e. Name and telephone number of the claim adjuster
f. Is the claim pending litigation? If litigation is pending, we will need the name, address, and telephone number of your lawyer.
Because we are sensitive to the fact that chronic pain is a complex problem we employ an inter-disciplinary approach to treatment at the NC Pain Management Services, PA. Effective therapy requires the use of a multi-modal approach, which is intended, to not only reduce the cause of the pain but also to achieve physical and psychological rehabilitation. Our team is made up of physicians specifically trained in pain medicine who are supported by a pain psychologist, physical therapists, biofeedback technician and nurses, all contributing their special expertise to alleviate the pain of each patient. Nerve blocks are seldom administered alone to the chronic pain patient without addressing the emotional factors and physical deconditioning underlying their pain syndrome. A wide range of diagnostic and clinical treatments is available to our patients. These include:
· Biofeedback
· Physical therapy
· Pain psychology
· Medication management
· Differential diagnostic nerve blocks
· Epidural steroid injections
· Selective nerve root injections
· Facet joint blocks
· Denervation techniques with radiofrequency or cryoneurolysis
· Intrathecal implantable drug administration pumps
· Implanted spinal cord stimulators
Although biofeedback was not initially developed as a treatment for the management of chronic pain it has become a useful tool for some chronic pain conditions. The biofeedback approach assumes that subconscious psychological or physiological response is partially responsible for some of the chronic pain and that control of this response will help lessen the pain. There are several methods of biofeedback which all measure a physiological function such as body temperature or muscle tension. Through the use of electrodes properly placed on the patient, these functions are measured and converted into an understandable form to the patient. In certain conditions such as low back pain and chronic tension headache it is believed that abnormal muscle contraction supports or bring about these pain syndromes. Through the use of biofeedback the patient is made aware of this abnormal tension. As the patient learns to control the abnormal muscle tension, a reduction of pain is often reported. NC Pain Management Services, PAÝ recommends supplementing biofeedback with classes in relaxation training.
Differential nerve blocks with the use of a local anesthetic and steroid can be a powerful tool to help the physician reliably diagnose the pain generator and it might be a useful form of therapy. Various injection treatments are used to reduce pain by blocking the nerve impulses carrying the pain message or by decreasing the inflammation in the painful swollen nerves by the use of injected steroids. Nerve blocks used alone are seldom of long-term value to the patient with chronic pain. However, by temporarily abolishing a patient's pain this will allow the patient a window of opportunity to participate in exercise and rehabilitation. Nerve blocks are also used in a technique called "Mapping", which basically consists of finding the source of the pain by systematically eliminating possibilities. This technique is highly effective in difficult cases, where most conventional diagnostic studies have been of little use. At the NC Pain Management Services, PA, the four most frequently employed steroid injections are:
· Epidural steroid injections
· Selective nerve root injections
· Facet joint injections
· Myoneural Blocks (Trigger Point Injections)
Epidural steroid injections are generally performed on patients with back and limb pain (neck and arm or low back and leg). In these conditions inflammation or irritation of the nerve roots may cause the spine and limb pain. The irritation of these nerve roots can be caused by arthritic degeneration of the spine or disc herniation. Local anesthetic and steroid is injected by the physician into the epidural space, which surrounds the spinal cord and nerve roots. Therapeutically, long-lasting relief of nerve root irritation as with small disk herniation can be obtained through the use of epidural steroid injections. The leg pain that occurs with disk herniation is believed to be the result of nerve irritation and inflammation from the release of chemicals from the damaged disks. The deposit of steroids in the epidural space counters the inflammation and decrease the pain. Many times the epidural steroid injections are performed in a series of three, spaced two weeks apart.
With the aid of fluoroscopic x-ray imaging it is not difficult for the pain physician to place a needle adjacent to the hole where a specific spinal nerve root leaves the spine. Injection of a small amount of local anesthetic and steroid in close proximity to the spinal nerve root may be more efficacious as the medicine is placed closer to the pain-generating site. Also it allows the pain physician to more reliably determine the source of the patient's pain. This information can be very useful if surgery is being considered.
It is a surprise to many that most back and leg pain is not due to disk herniation and spinal nerve root irritation. Failure to recognize this fact has led to a high rate of unnecessary disk surgery with poor results. In the search for other causes for back pain, attention has become focused upon the facet joints as a possible pain source. Facet joints are paired joints that connect the posterior elements of the vertebral bodies of the spine. These joints permit the vertebral bodies to glide over each other while the back is in motion. Throughout life, these joints are subjected to repetitive strain and eventually it is not uncommon for arthritic degenerative change to take place in these joints. This is a fairly frequent occurrence in patients by the fifth or sixth decade of life. Pain from these joints can be referred to the posterior chest wall to the hips, thigh and buttock region. Lumbar facet injections are used for patients with low back pain and leg pain stemming from inflammation of these joints. Similarly, cervical facet injections can be performed for patients with predominately neck pain as a result of degeneration of these joints. As with epidural steroids the facet joint injection is usually temporary. By temporarily abolishing the pain, the patient may participate in physical therapy with attention to abdominal strengthening and weight loss to diminish the abnormal forces, which accentuate the pain from facet joint arthritis. Our patients who receive facet joint injections have failed to respond to other conservative measures, such as rest, lumbar corsets, oral anti-inflammatory medications and physical therapy. Facet injections are performed using a C-arm fluoroscope to direct the needles through the skin into the facet joints. A mixture of local anesthetic and steroid is injected into the joint itself or in direct proximity to the nerve, which innervates the facet joints. These injections not only provide relief of pain and inflammation but also provide more diagnostic information to the pain physician. At the NC Pain Management Services, PA, when the pain recurs after the initial steroid injection and physical therapy, we provide more long-term relief by performing a procedure called facet denervation. After determining which facet joints are responsible for the pain syndrome, we can cause thermal lesions to the nerves, which innervate those painful facet joints. The procedure is done in an outpatient setting using the C-arm fluoroscope to guide the physician to place the thermal probe adjacent to the nerves that provide sensation to the involved facets joints. The pain relief after these injections may last 4-6 month, and occasionally, up to 18 months.
Trigger points are defined as areas of muscle, sensitive to palpation. These areas can occur in any muscle of the body but are generally localized in the upper and lower back muscles. "Myoneural" or "Trigger Point" injections are frequently done to these palpable areas and then physical therapy is instituted to get the best range of motion while the area is anesthetized. The tender areas are located and marked with a skin marker and then injected with long-acting numbing agents along with a corticosteroid preparation, through a thin needle. These medicines will help reduce inflammation and pain. Initially, the pain may feel worse but this quickly subsides and prompt relief is obtained.
Depending on each patient's condition, the best time to have your physical therapy done may be after a myoneural injection. Other modalities used by the Physical Therapy Department include moist heat, massage, cold pack application, TENS unit, spray and stretch, electrical stimulation and ultrasound.
Along with the myoneural injection, a non-steroidal anti-inflammatory drug may be prescribed. In addition, an appointment for biofeedback and relaxation techniques may be considered beneficial in your care.
Factors that have been identified as precipitating the formation of trigger points include excessive strain of any given muscle, poor nutrition, poor posture, endocrine or metabolic imbalances, mechanical discrepancies (i.e., one leg shorter than the other) and excessive stress or anxiety. Other phenomenon that have been identified as increasing the intensity of myofascial pain include smoking, cold or humid weather, fatigue, a sedentary state and overactivity.
At times, the NC Pain Management Services, PA, will encounter patients that have failed all previous treatments. These patients have failed to respond to multiple surgeries as well as multiple conventional methods of pain control. It the past, these unfortunate patients often had no option but to "learn to live with the pain." We can now offer some hope to these patients with spinal cord stimulation. Spinal cord stimulation is electrical stimulation at a precise level of the spinal cord. This stimulation causes a sensation of tingling in the area where the brain previously felt pain. The patient's pain is replaced by a tingling sensation. Patients who respond well to this therapy include those with Failed Back Surgery Syndrome, arachnoiditis, reflex sympathetic dystrophy and ischemic pain. This therapy is nondestructive and entirely reversible if it proves not to be effective for the patient. Careful patient selection is critical in determining success of this therapy. Spinal cord stimulation candidates undergo a trial of stimulation to determine whether spinal cord stimulation will be effective for them. The patient undergoes placement of the epidural electrode lead through the skin under local anesthesia. Patient cooperation is needed to ensure that a tingling sensation is felt over the area where the patient generally feels pain. During this trial period, which may last several days, the effectiveness of stimulation is tested using an external power source. Patients who experience significant pain relief during the trial will then have the internal generator (power source for stimulation) also placed under the skin under local anesthesia.
While spinal cord stimulation is preferred in patients whose pain is primarily in the extremities, intrathecal drug infusion is preferable in those patients with primarily back pain, whose pain may be in multiple sites. Spinal cord stimulation is more effective for neuropathic pain, which is pain related to pathology of the nerves. Intraspinal drug infusion therapy is effective in treating pain that is physical such as bony pain. Intrathecal (into the cerebrospinal fluid of the spine) infusion of narcotics such as morphine provides highly effective analgesia with one three-hundredth of the equally effective oral dose of morphine. With such small doses, side effects are usually minimal. Patients selected as candidates for intraspinal drug infusion therapy undergo a trial with a catheter inserted through the skin over a period of three days. If patients experience significant pain relief with minimal side effects such as nausea, vomiting and lack of appetite a totally implanted system with catheter and infusion pump is easily placed subcutaneously either under general or local anesthesia. Advantages of the fully implantable drug infusion pump include patient freedom from external devices and requirement for infrequent refills since the daily dose administered is so small. Non-invasive dosing changes can easily be made by the physician with a small programmable device. The higher initial costs of the medical device and implant procedure are offset over time by the lower maintenance and drug costs.
As Pain Specialists, our job is to evaluate each patient on an individual basis and determine what will be required to best manage their pain. Although we understand that some patients will require the long-term use of controlled substances, our goal is to avoid them as much as it is possible, due to the problems involved with their use. Whenever possible, we will provide and use alternatives to such drugs. Our program has been tailored to provide patient and medical provider education, as well as strict supervision over the use of these substances. All of our medication policies and rules exist for a reason. Most have been developed in accordance to Federal and State Regulations. Because we deal with substances that are regularly abused, we have adopted a "Zero Tolerance Policy". Violation of any of our regulations is considered a breach of trust in our patient-physician relation, with subsequent immediate dismissal from the program.
Medicine is not an exact science, and as such, no guarantees
can be made. It is very likely that no matter what we do, you will continue to
have "good days" and "bad days". This is just the way life
is. Nevertheless, our hope is to be able to tilt the balance so that you end up
with more of the "good days", rather than the bad ones, and maybe
provide you with alternatives on what to do during those "bad days”.
Before we consider prescribing any medications for your pain, you will need to be aware and familiar with the program's guidelines and regulations pertaining to these medications, and agree to follow them at all times. In addition you will also need to be aware of the risks involved with the use of such medications. Please take the time to carefully read this document.
1. Initial Patient Evaluation- No controlled substances will be prescribed on the patient’s first visit to the Pain Clinic. By law and by the State's Board of Medical Examiners, we are required to gather a comprehensive medication history before beginning the prescription of these substances. It is also our policy not to write prescriptions for controlled substances, before the Narcotic contract is signed. The law requires that there be a patient-physician relationship established before treatment is undertaken. Prescriptions will not be written for any non-patients.
2. Controlled Substance Agreement- This Agreement must be read and signed before any prescription medications are to be dispensed. It contains important information pertinent to the use of these substances.
3. Telephone Calls- No prescriptions will be "refilled" or "called in" to any pharmacies over the phone. Also no prescriptions will be faxed. In addition, no medication changes will be made over the telephone. This policy applies to refilling prescriptions and starting new medications.
4.
After
Business Hours, Holidays, and Weekends- No prescriptions will be written at
these times. Prescriptions will be written only during regular business hours.
Therefore, it is the patient’s responsibility to keep track of his/her
medications in order not to run out of them during those times.
Business hours are:
Monday ń Thursday from 8:00AM until 3:00PM.
Fridays from 8:00AM until Noon.
5. Drug Screening Test and Follow-up - By law and by the State's Board of Medical Examiners, we are required to maintain adequate documentation with regards to our patient’s use of controlled substances. Therefore, you may be required to provide urine or blood samples for the purpose of drug screening tests. It is unethical and illegal to prescribe medications without adequate follow-up. Therefore, not keeping your regular appointments constitutes a violation of this follow-up policy, possibly resulting in the discontinuation of the medication.
6. Sharing Medications- This is strictly prohibited. Medications are to be taken only by the patient for which they were intended.
7. Selling or Distributing- This is strictly prohibited by State and Federal Law. This is an illegal practice and could carry jail-time.
8. Lost or Stolen Medications or Prescriptions- Will not be replaced. We do not accept "police reports" as proof.
9. Obtaining Pain Medications from more than one physician- This practice is called "Doctor Shopping" and State Law strictly prohibits it. This is an illegal practice and could carry jail-time.
10. Picking-up prescriptions without an appointment- This practice is not permitted, especially by someone else for whom the medications were not intended. Patients must attend their appointments in order to be assessed for the need to continue taking the medication. Prescriptions will only be handed to the patient for whom they were intended, and only during regular appointments.
11. Identification- Patients may be required to produce a current, valid Photo I.D., before receiving a prescription for a controlled substance.
12. Driving or Operating Heavy Machinery- This is strictly prohibited when taking controlled substances. In certain cases, an evaluation by an Occupational Therapy Team may be required to determine if the patient could operate such vehicles.
13. Handling Firearms or other Weapons- This is strictly prohibited when taking controlled substances.
14. Pregnancy or Lactation- It is strictly prohibited to take controlled substances when pregnant or lactating. Taking controlled substances while pregnant may cause fetal abnormalities as well as fetal addiction and perinatal withdrawal syndrome.
15. Use of Alcohol- This is strictly prohibited when taking controlled substances. Combining alcohol and pain medications may result in death.
16. Illegal Drug use- This is strictly prohibited and may lead to discharge from the program.
17. Using suicide as a threat- This will result in immediate discontinuation of all pain medications and mandatory, possibly involuntary, institutionalization in an in-patient psychiatric facility.
18. Suicidal attempts- This is not a psychiatric-based pain program. Suicidal attempts will result in immediate and complete discontinuation of all medications with the potential to be used to harm the patient. Furthermore, the care of the patient will be transferred to a psychiatric-based pain program.
19. Unused Portion of Prescription- Prescription medications should be taken to all of the Pain Clinic's appointments for the purpose of drug counts. Discontinued medications should also be taken to your appointments for the purpose of being discarded with adequate documentation and in front of witnesses. A sample may be sent out for analysis and identification. We will not accept video recordings as proof of disposal.
20. Medication Prescriptions- Will be issued only in the clinic, during regular business hours. Nothing will be called in, faxed, or mailed. This is done for the purpose of maintaining adequate control and documentation on the distribution of these controlled substances.
21. Mail-in Prescriptions Services and Medication Assistance Programs- We cannot be responsible for the handling of your prescriptions or your medications by a third party. When using either one of these medication services, be advised that we are not responsible for problems that you may run into when using them. If your prescriptions or medications are lost in the mail, or there is any delay in the shipments, we will not be issuing additional prescriptions "to keep you until the medicines arrive". Also, we will not be "calling them for you", to speed up the process, or to see what is happening. In addition, there are "Mail-in Prescription Services" that require that a prescription for a 90 day supply be written, instead of one with refills. We believe this to be inappropriate and unsafe, when dealing with controlled substances. Because of this, we will not be writing for such prescriptions. In general, we do not believe "Mail-in Prescription Service Programs" to be appropriate for "Controlled Substances". If a medication is lost in the mail, we will not be replacing it. We do not accept "U.S. Postal Service Mail loss/rifling report" as proof of loss.
22. Multiple Pharmacies- This is not permitted. Patients most agree to use only one pharmacy to obtain their pain medication. This pharmacy will be of the patient’s own choosing. The patient is responsible for providing us with the name, location and telephone number of the pharmacy of choice. If for whatever reason the patient decides to change pharmacies, this is permitted, but the patient must immediately provide us with the name, location and telephone number of the new pharmacy.
23. Sharing and obtaining information- The patient must agree to allow his/her pain physician to share and/or obtain medication related information with/from his/her other treating physicians. This is essential if medication interactions are to be avoided. The patient also agrees to allow the pain physician to freely discuss his/her case with any other physician currently or previously involved in the patient’s care.
24. Nerve Medicine- Will not be prescribed by our program. The patient understands that our pain program will not be prescribing medications for the "Nerves". Specifically, benzodiazepines such as Valium (diazepam), Xanax (alprazolam), or Ativan (lorazepam). If the patient is currently taking these medications, they must continue to be prescribed by the physician that initiated the therapy, or a licensed psychiatrist.
25. Recommended Care for your medicines:
a. Always bring your medications to your appointments.
b. Keep all of your medications away from children. It is best to keep them under lock and key, even if the patient lives alone.
c. Always open your bottles over a counter or table, so that if they fall out you may be able to collect and use them. Never open the bottle over the commode. We will not replace damaged medications.
d. Do not discuss with others about the types of medicines that you take. There is an ongoing scam, where certain elements of our society look for people willing to make this information available, most commonly in pharmacies or even the waiting room of a pain practice. The unsuspecting patient is then either assaulted and the medications taken, or followed home, where they patiently wait for an opportunity to break in and steal the medications.
e. Never carry more medicine that what you will consume during that day. If your medication is lost or stolen, you will be out of it for only one day. Remember, we will not replace lost or stolen medications.
f. Always keep your medications under lock and key, even if you live alone. We have had cases of visiting friends who may come with someone else, unknown to the owner of the house, who have stolen the medications on an innocent trip to the bathroom.
g. Always know how much medicine you have left and if you need a refill. It is your responsibility to know when you are running out of medicine. Adopt an "Early Warning System" - We recommend that you put aside, in a separate (well-labeled) container, seven (7) to ten (10) days worth of pain medicine. Then use the remainder, like you normally would. When the primary supply runs out, then you know that you have seven (7) to ten (10) days worth of pain medicine left and that you need to arrange for an appointment to have your medications refilled.
Tolerance is what happens when your medicines are no longer as effective as they use to.
Tolerance. Tolerance may be acquired to the effects of many drugs, especially the opioids, barbiturates, and other CNS (central nervous system) depressants. When this occurs, cross-tolerance may develop to the effects of pharmacologically related drugs. Tolerance to a pain medication will be manifested as an increase in pain after the frequent use of the analgesic (pain medication). Tolerance has been described to develop in as short as 10 to 28 days. Although this process may take as long as a year in some patients, it is safe to assume that it will occur to everybody who takes this type of medication on chronic basis. In our practice, we try to assess the patient’s narcotic requirements in as short of a time period as possible. As soon as the patient admits to be comfortable on a certain dose, we call such a dose "the patient’s requirement." Thereafter, any increases in the pain, within an otherwise stable condition, are considered to be due to the development of tolerance. A common complaint of patients is that, "the medications don˘t seem to work as well as they use to."
This is a very common misconception held by patients, as well as physicians.
Misconception. It is thought that changing from one narcotic to another prevents and treats the development of tolerance. It doesn't. All narcotics bind to the same set of opioid receptors. There is not a receptor for hydrocodone, one for oxycodone, another to morphine, etc.. Since the problem with tolerance is one at the receptor level, changing the medication is not going to correct it. It is like having a faulty light-switch and thinking that you can correct the problem by changing the finger that you are using to try to activate it. Switching from one narcotic to another does not help. In fact, it complicates the medication management, since it introduces more variables. Most physicians who do this, do not know what the equivalent amount of one narcotic to another is, therefore, when they substitute it, they tend to give the patient more of the new medicine. This gives the patient and the unsuspecting physician the illusion that it has worked, when in fact the only thing that has been accomplished is an increase in the narcotic dose.
When you develop tolerance to a narcotic or opioid, you develop it to the entire family, through a process known as "Cross-Tolerance". Therefore, even if a pharmaceutical were to develop a new narcotic tomorrow, you would still be tolerant to it, just because of the fact that it is still in the same family of medications.
Fact #1. Most of the tolerance seen with opioids is due to adaptation of cells in the nervous system to the drug's action. The use of increased amounts may in turn enhance the risk of toxic effects or produce other problems if the drug is expensive or obtained illicitly. Although the "lethal dose" is greatly altered in tolerant individuals, a dose always exists that is capable of producing death from respiratory depression. Tolerance to opioids largely disappears when withdrawals have been completed, and many addicts have taken fatal overdoses by returning to their previous dosage immediately after undergoing withdrawal.
Fact #2. Increasing the dose will only treat the problem temporarily. Tolerance will again occur at the higher dose. The higher the dose, the worse the withdrawals, the more money it will take to buy your medicines, and the more likely that you will have side effects. In addition to this, the higher the dose, the more likely it is that your physician will be uncomfortable with prescribing it and the more likely that you will not find anybody to continue prescribing it for you.
Fact #3. Most short-acting narcotics are "combination drugs", meaning that they exist as a mixture of two drugs. (ie. Percocet = Oxycodone + Acetaminophen [Tylenol]; Vicodin = Hydrocodone + Acetaminophen) Because of this combination, it is dangerous to take them for prolonged periods of time or in high doses, not because of the narcotic (Oxycodone, Hydrocodone), but because of the Acetaminophen (Tylenol), which will permanently damage your Liver. Acetaminophen toxicity can cause Liver necrosis (organ death), requiring treatment by way of a "Liver Transplant".
Drug Holidays. This is the name given to the period during which the medications are stopped. Drug Holidays should always be tailored to the pharmacokinetics of the medication for which it is intended. (ie. in the above mentioned example for morphine, they should be 7 to 10 days in duration while in the case of methadone, they should be 3 weeks in duration.) During the Drug Holidays, clonidine can be administered for one week, to help with the hyperactivity of the sympathetic autonomic nervous system. This medicine will lessen the withdrawals, but will not completely get rid of them. During the Drug Holidays, because of cross-tolerance, patients should not be allowed to switch to another opioid. When returning to the opioid, at the end of the Drug Holiday, the patient should always be started at a lower dose than the dose prior to the Drug Holiday. They should be repeated as often as necessary to allow the patient to control his/her medication intake, rather than allowing the medication to control the patient.
Withdrawals. Contrary to withdrawals from alcohol or benzodiazepine (VALIUM, ATIVAN, XANAX, etc.), narcotic withdrawals are, for the most part, not lethal. In the case of short acting narcotics, such as morphine, withdrawals can occur 12 to 14 hours after the last dose, reaching their peak at 48 to 72 hours, and disappearing in 7 to 10 days. With longer acting narcotics, such as methadone, withdrawals can begin 24 to 48 hours after the last dose, reaching a peak at the 3rd day, and may not begin to decrease until the 3rd week.
Symptoms of withdrawal: They usually consist of lacrimation, runny nose, yawning, sweating, dilated pupils, loss of appetite, goose bumps, restlessness, irritability, tremors, insomnia, sneezing, weakness, depression, nausea, vomiting, diarrhea, abdominal cramps, chills, bone and muscle pains, increased in respiratory rate, heart rate and blood pressure, muscle spasms, cold and hot flashes, increase in body temperature, anxiety, and a feeling of being ready to "climb up the walls" or "jump out of your skin". For the most part, withdrawals are more severe for the short-acting narcotics than for the long-acting.
Reason #1. (Physiological Reason). By withholding the medication from the receptors, a physiological process of "Receptor Down-regulation" occurs, by which "Tolerance" to the narcotics decreases and occasionally disappears. When the medication is restarted, it will usually be more effective in controlling the symptoms (pain).
Reason #2. (Medico-Legal Reason). Federal Law defines an "Addict" as "someone who has lost self-control over their own medications". Following this definition, it then states that "it is illegal for any physician to prescribe narcotics to an addict". Because of this, any patients refusing to undergo a "Drug Holiday", may be considered as having lost self-control over their medications, subsequently triggering the permanent cessation of all controlled substances by the prescribing physician. The other side of that coin is that by complying with the "Drug Holidays", the patient proves that he/she continues to have self control over their own medicines, and therefore, it makes it legal for the treating physician to continue prescribing the pain medication.
It should be at least two (2) to three (3) weeks long. The rule of thumb is that it should continue, as long as the patient continues to exhibit symptoms of withdrawal.
Yes, you may use non-steroidal anti-inflammatory drugs for that pain; muscle-relaxants for the muscle pain and spasms; and, clonidine or Zanaflex ’ for the withdrawal symptoms. In addition to this, you may continue to use your other medically indicated medications, for your other chronic medical conditions (ie. diabetes, etc.).
No, you cannot switch to another narcotic or continue taking any other narcotics during your "Drug Holiday".
When your pain medication begins to lose effectiveness. When you see that your pain medicine is not working as well as it use to.
It all depends on how quickly you develop tolerance. Some patients are lucky and may develop it over a period of a year, in which case they will have to undergo a "Drug Holiday" once a year. On the other hand there are some that are not as fortunate and may develop tolerance over periods as short as twenty-eight (28) days, in which case, they may have to do one every month. The later, may not be a good candidate to stay on this type of medication, precisely because of this reason.
As previously stated, you may actually make it illegal for your physician to continue prescribing the medicine for you. Therefore, you may find yourself coming off of the medicine forever, rather than just two (2) to three (3) weeks. In addition to this, if you are not to follow your physician's recommendations, then, you should not be seeing that physician.
In that case, you may not be a candidate for Narcotic therapy, at all. Rapid drug escalation is a sure recipe for disaster. This should be avoided whenever possible.
No. We do not hospitalize any patients for “Drug Holidays". If you feel that you will not be able to stop your pain medication without being hospitalized, then we will need to closely evaluate your case for possible "addiction" issues. Addiction involves psychological craving, and/or an unsubstantiated fear to stopping the medication. In these cases, you need to check yourself into a "Detoxification" program, such as "Charter's". Once you are completely off of the medication, we would probably avoid going back to it, since this condition can relapse.
NC Pain Management Services, PA is dedicated to serving our patients with the highest quality of care at the lowest possible cost. We ask that you help keep our fees at a competitive level by observing the following financial policy. The purpose of this statement is to help you understand our policy in relation to Pain Clinic charges. We encourage open discussion of services and fees prior to treatment. It is your ultimate responsibility to see that all charges are paid.
You will receive two bills for your services. One bill from NC Pain Management Services, PA, which includes the professional services of our clinic physicians, and you may call our toll free number 1-(803)-356-2888 with any billing questions. The other bill will be from Alamance Regional Medical Center, which includes the facility fee (i.e. nursing and technician services, supplies, and equipment). Questions regarding the hospital bill should be directed to the hospital's "Patient Accounting Office" at 1-(336)-538-8400.
The rest of this financial policy information is specific for NC Pain Management Services, PA and therefore any questions should be directed to our physician billing service, currently "E.J. and Associates, LLC", at our toll free number 1-(803)-356-2888.
Since insurance plans vary, we recommend that you be familiar with your plan benefits as they relate to deductibles, co-pays, non-allowed charges, and pre-certification. Your insurance coverage represents a contract between you and your insurance carrier. If you have an insurance policy, such as an HMO/PPO that requires pre-certification / pre-authorization or referrals for any service, including office visits, it is your responsibility to obtain it, update it, and keep them current. If you need any help, our staff will be more than happy to help you through the process. In your insurance card there will be a telephone number, which is the number that you should call for pre-approvals or information on deductibles, co-pays, allowable, and pre-certification. You can also use this number to find out what your insurance company allowable is, for the proposed treatment. If you have any questions about the requirements of your coverage, please contact your employer or insurance carrier. We cannot interpret policies for you. Remember that the difference between the allowable and the cost of the treatment will be your personal responsibility. You will be responsible for services rendered that are outside the scope of any referral issued by your insurance carrier. You are expected to be aware of any and all conditions of your insurance coverage. Please provide us with information on any secondary insurance coverage that you may have, as they may cover the difference.
Your co-pay is due at the time of your service. Your co-pay may be paid in cash or with a check, at the time of your service, or it may be paid using your credit card, within two (2) weeks of your service. (Credit card option will be available by May of 2003.) Please indicate your preference to the receptionist, at the time of your service.
Nobody can turn a denial for coverage more effectively than the patient. If your insurance company has denied coverage for the proposed services, our physicians will be more than happy to write a "Letter of Medical Necessity". Despite this, some companies will continue to deny coverage, in which case, it becomes the patient’s responsibility to try to overturn the decision, otherwise, the responsibility for payment becomes entirely yours. We will provide you with the information necessary for you to request a review of a denied claim, or to follow up on disputed claims. It is your responsibility to follow up on any outstanding claims, and to see that your carrier pays promptly. Claims status does not relieve you of your responsibility to pay your bill. Be aware that for some insurance carriers, granting authorization for treatment, does not mean that they will actually pay for it. Denial of payment after pre-approval or authorization will make you responsible for the charges.
Filing claims with and accepting benefit assignment from your insurance company is a courtesy to patients provided by many physician offices. However, an increasing number of physician offices require full payment at the time of service and the patient is responsible for securing payment from the insurance company. When a medical practice chooses to help patients by filing for insurance payments, the result to the physician is that he often waits 45 days or more for payment. NC Pain Management Services, PA has chosen to continue to work with insurance companies for as long as possible to make it easier for patients to receive the specialized healthcare they need. This means both our patients and we have certain responsibilities.
· File claims with insurance companies in a timely manner
· Send appropriate documentation of procedures and medical necessity when necessary
· Post payments received in a timely fashion
· Send statements of account activity and patient balances due in a timely manner
· Provide us with current insurance information
· Provide us with current information on your secondary insurance
· Update our office when insurance coverage and personal information changes
· Obtain pre-certification for services from your insurance carrier (telephone number is in your insurance card)
· Pay co-payments and unmet deductibles at the time of service
· Pay outstanding balances when you receive statements
· Work with employers and insurance companies if collection from insurance companies becomes a problem
· Stay in touch with our billing office regarding your account
To help us provide the most efficient and reasonable health care services, we need your insurance information to be accurate, complete, and up-to-date. The balance due is your responsibility if we do not received payment from your insurance company within 30 days. Therefore, you may receive a bill after those 30 days. If we receive duplicate payment from the insurance company, we will promptly refund to you any overpayment.
We ask that you pay ahead of time on the balance or any unmet deductible that is your responsibility. For Medicare patients, we will wait until we have received payment or other response from Medicare before billing you for any remaining balance due. Since we are not a party to the agreement between you and your insurance company, we ask that you assist us in contacting them if they have not paid for your services within 30 days. If you perceive that your plan does not pay benefits as dictated by your insurance contract, we suggest you contact the insurance company directly. We regularly review our fee schedule and believe our fees to be reasonable; therefore, we will not become involved in disputes over usual, customary, and reasonable charges, as determined by the insurance company.
For Worker's Compensation claims, it is our policy to bill your employer or the Worker's Compensation carrier for services rendered. However, you must bring proof of acceptance of the claim, complete billing information, and authorization from the compensation carrier. Otherwise, you will be responsible for all fees incurred. If you are covered, we will accept the payment made by Worker's Compensation as payment in full. If Worker's Compensation denies payment or goes into litigation, the entire balance will become your responsibility and will be due within 10 days of the date of the denial. We will, however, as a courtesy, bill your private health insurance plan, if you provided us with the appropriate information at your initial visit. For this reason, and for your protection, we ask that you provide complete information on all your health insurance at the time of your initial appointment.
We do not hold bills for pending litigation or bill attorneys for services rendered to patients. Presenting a letter or representation from an attorney does not alleviate you of the responsibility for your bill. If your treatment is required as a result of an accident, and your health insurance has agreed to cover it, we will file your group health insurance. If your health insurance carrier will not cover our charges because of third-party liability insurance, we will expect payment in full at the time of service.
If you do not have any health insurance and are not covered by Medicare, Medicaid, or Workers Compensation, you will be considered a "Self Pay" patient. Payment is due at the time we deliver services to you, and we require that you make payment in full at the time of your visit. This assists us in reducing billing and operating expenses that inevitably get passed on to patients.
If you anticipate balance due creates a financial hardship, we will be happy to work with you to establish a monthly payment plan. Your need for potential payment arrangements should be discussed before services are rendered. Payment plans may not be set up once accounts reach delinquent status. The agreed on amount must be paid monthly, or the account balance will become due in full.
A Charge may be incurred for unkept appointments unless you have provided prior notification of your inability to honor your scheduled appointment, 24 hours in advance. There will be a charge for phone calls answered by physicians. Payment will be due, along with your co-pay, at the time of your next visit. Starting on May of 2003, you may pay this by using your credit card, via the above provided telephone number.
We ask that you read this policy and assist us in keeping our costs down by ensuring that we can be paid on a timely basis for our services. We welcome the opportunity to discuss with you any aspect of our financial policy.
1. Providing us with current and updated information on yourself and your insurance coverage and advise us immediately of any changes in insurance coverage, personal address, etc.
2. Making payment at the time of service for the entire balance if you are a "Self Pay" or "Self-Insured" patient or for the amount of the deductible or co‑payment, if you have insurance.
3. Keeping your balance current or continue to make regular monthly payments on your balance.
4. Discussing your account status and balance only with the check‑out staff or our billing staff.
Please do not discuss the financial aspects of your care with the physician(s). It is important for them to be allowed to practice medicine and provide patient care. We have employed the services of a professional billing staff that is familiar with the services we provide and with all of the insurance plans with which we participate. Please call them toll free at 1-(803)-356-2888 anytime you have questions about your coverage or your account.