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Top 15 Business Strategies for Enhancing Your BOTOX Migraine Clinic

Date: 03/07/2024
American Headache Society Practice Tips
  1. Use BOTOX (Allergan/Abbvie) only. While multiple types of botulinum toxin are available, only onabotulinumtoxin-A (BOTOX) is currently FDA-approved for treatment of chronic migraine. Substituting other botulinum toxins may lead to non-payment of services by insurance.
     
  2. Successful authorization requires correct documentation. Individual insurers have different step requirements which should be identified. At a minimum (a) document the diagnosis of chronic migraine using ICHD-3 criteria, (b) document failure of all prior migraine preventative therapies. A specific statement, such as “chronic migraine present for > 15 days per month for > 3 months with episodes lasting > 4 hours in duration” is often useful. You may also need to document the absence of medication overuse headache.
     
  3. Carefully consider the risks of “buy-and-bill.” Advantages of “buy-and-bill" include access to drug for both provider and patient; and a small insurance reimbursement premium on drug over the purchase price. Disadvantages include the risk of non-payment of services and drug by the insurance carrier (denial) and significant cash-flow burdens carrying thousands of dollars of expenses related to delayed or denied insurance payments. If you “buy-and-bill”, ensure you include the J code: J0585 with the CPT code: 64615, and connect both to your chronic migraine ICD-10 code.
     
  4. Use specialty pharmacies to obtain BOTOX serum. To counter the above risks associated with “buy-and-bill” use specialty pharmacy options. Non-payment risks will be completely avoided and your office will have zero cash-flow consequences. The principal disadvantage is that some insurances will not permit BOTOX access via specialty pharmacy.
     
  5. Appoint a BOTOX coordinator. Assign a specific individual who will supervise prior authorizations, BOTOX orders, specialty pharmacy shipments, cross-referencing, and patient appointments.
     
  6. Allow at least 4-6 weeks for the prior authorization and specialty pharmacy process. Follow up with insurance and specialty pharmacy weekly to address pending authorizations. Document all phone calls and contacts (including names and times) as you will often be interacting with different representatives each call.
     
  7. Create BOTOX days. Designate specific days of the month when you will administer BOTOX. All patient slots for the half- or full-day should be for BOTOX only. Avoid new patient, revisit, or work-in visits. If a patient needs to cancel an appointment, reschedule them only on the next BOTOX day. A BOTOX day allows the provider and staff to remain focused on a single task the entire day, increasing efficiencies.
     
  8. Have a trained medical assistant draw up BOTOX serum for the provider and document lot and vial numbers in the electronic medical record. Maintain a separate paper binder of all BOTOX patients, injection dates, and BOTOX serum amounts and lot numbers.
     
  9. All BOTOX patients should be scheduled for their next visit at the time of their current injections. This will require your office to have at least a 3 month open calendar for visits.
     
  10. Create and use a BOTOX template on your EMR. This will save valuable time during injection visits.
     
  11. Use the PREEMPT injection paradigm for chronic migraine (31 injections in 7 areas with a total of 155 to 195 units). Document total number of units used as well as units discarded.
     
  12. Be rigorous in documenting headache frequency pre- and post-BOTOX administration. Many insurers will require at least a 7-day improvement in frequency or severity for maintenance of therapy. Patients must keep a headache calendar.
     
  13. Administer at least 3 cycles of BOTOX to determine efficacy.
     
  14. Do not schedule a patient for an E/M visit with a Botox visit on the same day. Insurance carriers may not agree to cover both in 24 hours.
     
  15. Enroll your patients in the BOTOX Savings Program. This program provides up to $4000 in savings per year for commercially insured adult patients and includes reimbursement for out-of-pocket costs related to specialty pharmacy and professional services. Details are available at www.botoxsavingsprogram.com.

About the Author

Marshall C. Freeman, MD, FAHS is the Director of the Headache Wellness Center in Greensboro, North Carolina. Dr. Freeman has authored and co-authored numerous articles and textbook chapters on headache medicine and neuromuscular diseases. He lectures throughout the United States as a headache expert. He serves as Chief Medical Officer of Headache Wellness Center Research (HWCR) and as principal investigator on multiple headache studies.