If the data tell us anything, the demand for transcutaneous electrical nerve stimulation (TENS) is unlikely to go away anytime soon. For starters, some 86 million Americans suffer from chronic pain. What is more, many of today’s TENS patients are older Americans and that demographic is growing. Geriatric patients—many of whom suffer from chronic conditions like arthritis and degenerative disc disease—are proving to be a significant market for TENS providers.

Yet providers who specialize in the TENS market say there is not much that is new in the field over the past decade or so. They are referring to technological advances. However, there is plenty new in the way of challenges—including foreign brand units, continued reimbursement cuts, and new competition ranging from chiropractors to the Internet. Even so, TENS is still a viable market for providers with expertise and a strong commitment to service.

Educate Yourself, Your Patients
If you plan to succeed in the TENS market, the first rule is to make yourself an authority on the subject. “General HME providers shy away from TENS because they are simply not comfortable,” says Keith Lanford, owner of L&L Medical Inc, Huntsville, Ala. “TENS is a specialty that requires a good deal of time and commitment.”

Smart TENS providers make it a priority to educate themselves so that they can provide proper instruction to patients. There are a number of ways to get up to speed on TENS. You can review manufacturers’ videos and studies, attend educational conferences, and talk with physical therapists. Gain as much expertise as possible, and you will be in a far better position to succeed.

Knowledge is what will keep you competitive. Consider, for example, that most insurance companies require a 1- to 2-month trial on a TENS unit before they will approve it for purchase. That means your bottom line depends on patient compliance and successful results. “The better the unit works, the more you will convert from rental to purchase,” says Lanford.

In other words, patient education is absolutely crucial to long-term success. The biggest mistake a provider can make is to simply mail the unit to the patient’s home. TENS units are complex and call for careful one-on-one instruction—even more so when the patient is elderly. You will want to spend ample time and attention on the initial setup.

For example, it is important to teach the patient about proper electrode placement, skin care, and setting adjustments. The more you know, the better you can communicate the intricacies of the unit and the treatment process.

An Hour for Setup
Henry Turner, owner and general manager of Birmingham, Ala-based Innovative Medical Inc, spends nearly an hour on the initial setup. “If TENS is used properly and consistently, it can be very effective in managing pain,” says Turner. “We view the time spent during the setup as an investment that pays off in the long run.”

Thorough follow-up with patients is as essential as the initial setup. Today’s geriatric patients, for example, are sometimes uncomfortable with technology or may be forgetful about ordering supplies. The best providers follow up with phone calls to ensure the unit is working, to check if the patient is experiencing any skin irritation, and to refurbish supplies. The better your follow-up, the better your chances for successful treatment.

Battle of the Brands
Keeping patients compliant through proper education is a challenge that has been around since TENS therapy began. A more recent challenge is the plethora of less expensive foreign brand units, which mean smaller profit margins for providers. “Imported units dominate the market today,” says Lanford. “DME providers are forced to buy the lower cost units to stay in business.”

Prices on domestic TENS units have dropped significantly as a response to foreign competition. Some of today’s domestic units are selling for half of what they did 5 years ago. While foreign brands can take a bite out of your business, providers say that at least the quality has improved. “Initially, the foreign brands were junk,” says Turner. “But the quality has risen dramatically over the last 3 or 4 years.” In fact, Innovative Medical’s return rate for defective units is now higher on American-made brands.

To make matters more difficult, manufacturers are driving up costs by producing TENS units with special features like compliance meters. Turner thinks manufacturers are missing the point. “Most doctors and physical therapists want a basic TENS unit that does the job,” says Turner. “Bells and whistles cost more, but reimbursement is the same as on a basic model.”

It would be one thing if breakthrough technology were driving up costs. But the experts say today’s fancy features are more like accessories than innovations. “There is nothing new in TENS in the past 15 years,” says Lanford. “The technology has not changed and the basic equipment is the same.”

Reimbursement and Billing
Today’s TENS providers say they must operate leaner than ever before. Reimbursement has dropped year after year. “In the 15 years we have been in business, reimbursement has dropped dramatically by 50%,” says Lanford.

With the cuts come changes in the way providers do business. Gone are the days when providers let a patient have a unit on a free trial basis—sometimes for up to a month. Few providers can afford to do it anymore. After the trial basis, the unit needs to be cleaned and serviced. Costs like these cannot be recouped.

It is not just the cuts that have an impact on TENS providers. It is knowing how to collect, too. “Billing for TENS is not like billing a wheelchair or a hospital bed,” says Turner. “You have to really know what you are doing to get reimbursed.” For general HME providers just entering the niche, a wrong diagnosis on the paperwork can cost you money.

Because a good number of TENS patients are older, a good deal of your claims will be submitted to Medicare. Lanford says TENS providers need to keep on top of changes in Medicare rules. For example, a recent change requires TENS patients to have a follow-up visit with their physician before they can purchase a unit. “It is important to know this for billing purposes, but also to clarify the requirement with the patient at the initial setup,” says Lanford.

According to Turner, it is vital to have a knowledgeable person dedicated to the billing function. You will need to ask all the right questions up front, look for red flags, and thoroughly understand the rules. Often, the biggest challenge is getting busy physicians to complete a certificate of medical necessity (CMN) in a timely manner. Medicare requires a CMN for the provider to be paid. When physicians hold up the process, your cash flow slows down.

Unexpected Competition
In the last few years, some new and unexpected players have entered the TENS market. Chiropractors across the country have become a force to contend with. In search of a new revenue stream, chiropractors are stocking units and selling them direct to patients.

Many providers believe chiropractors have an unfair advantage since they do not need a prescription or a CMN to put a unit on a patient. “Chiropractors have no extra steps to take and no one to answer to,” says Turner. “It is a conflict of interest because they have something to gain financially.”

In some cases, chiropractors are accepting “fitting fees” from unscrupulous dealers in return for referrals. The providers we spoke with questioned the integrity of these situations. “Anytime money changes hands between a referral source and a provider, something is wrong,” says Lanford.

Whether it is selling direct to patients or accepting a fitting fee, chiropractors appear to be the new competition that is here to stay. The consensus among TENS providers is that chiropractors have been bad for the business. It is not just that they are taking business away from providers, it is that chiropractors are not giving good instruction to patients. Worst of all, say providers, chiropractors have been undiscriminating—putting units on virtually everyone who walks through their door.

Another nontraditional competitor is the Internet. “You can find TENS units for as little as $50 on the Internet,” says Lanford. “But in my experience, most people would rather go through their insurance.”

While the FDA requires a prescription for a TENS unit, providers say it is not being enforced with Internet sales. You will find businesses selling new units online as well as consumers selling used ones on EBay. While Internet competition is a reality, smart providers know how to discourage patients from going the online route. “I remind people that if they order a unit off the Internet and then have problems, there is no one to call for help,” says Turner.

Still Profitable Despite It All
Clearly, increased competition, reimbursement cuts, and low-cost brands have led to smaller margins for TENS providers. “TENS is not the opportunity it was a decade ago,” says Lanford. “But you can still be profitable if you do the right marketing.”

Successful TENS providers still build their business the old-fashioned way. They earn the trust of physicians and physical therapists. “The best strategy for generating referrals is to deliver good patient care,” says Lanford. “If the patient is not complaining, the doctor knows you are doing your job.”

As a TENS provider, you will want to cast your net widely, calling on orthopedists, neurologists, family physicians, and pain clinics. Because the demographic for TENS patients has gotten older in recent years, geriatric physicians are a new source to tap.

It is important to stay visible with physicians. Many doctors do not know where to turn for units and need a solid source. Face-to-face meetings are also opportunities to establish yourself as an expert in the doctor’s eyes. Provide a brief demonstration and leave the physician with clinical articles and success stories.

The more knowledgeable you are, the easier it will be to win over new physicians. “Eventually, a doctor will send you a few patients,” says Turner. “If you help those patients get good results, you will see a sudden increase in referrals.”

There are times when a physician may need convincing before ordering a TENS unit. One provider says he uses the recent news about prescription drug abuse as a marketing tool. Physicians are under pressure to find alternative treatments to medication, and TENS is an alternative with a strong success rate.

Physical therapists are vital to growing your business, too. L&L Medical receives 50% of its referrals from therapists. Superior service can set you apart with therapists. At clinics, business is done on a consignment basis. You will score points by ensuring timely delivery and pickup of units, supplies, and paperwork.

Physicians and therapists alike appreciate personal attention and responsiveness. “It used to be that the larger companies owned the TENS business,” says Turner. “Now it seems that doctors and therapists want to deal with local providers who are accessible and supportive.”

While the technology has remained virtually the same, the landscape has changed radically for TENS over the last decade. Providers can not deny the shrinking margins and stiffer competition—still, many of them are sticking it out. For some, it is because they have built a solid referral base. Others anticipate an upturn in the market as the population continues to age. But for most, the reasons go beyond the bottom line. “There is something very satisfying about TENS,” says Lanford. “You can literally change someone’s quality of life.” DP

Marianne Matthews is a contributing writer for Dealer/Provider.