A Medicare beneficiary learns a lesson
Outdated regulations prevent patient from choosing a premium high-tech IOL.
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Telephone calls to my office usually come from doctors, lawyers, office managers and anyone connected with billing and filing claims. So I was surprised when my secretary announced that Dr. Abrahams patient, Mr. Singh, wished to speak with me. Somehow, Mr. Singh had learned that I am the reimbursement consultant for eyeonics, the manufacturer of a new accommodative IOL, the Crystalens. He was seeking answers to his questions about possible Medicare coverage for his cataract surgery using this state-of-the-art IOL.
Patient background
During the first of many phone calls, Mr. Singh explained that he was a retired engineer, a Medicare beneficiary and had cataracts that were bothering him more and more over the past year or two.
Mr. Singh had just learned that the Food and Drug Administration had granted approval for the Crystalens in the United States. He wanted to know if Medicare would cover his cataract surgery with this IOL. Mr. Singh was exceptionally well informed. He knew that the Crystalens was different from other IOLs because it can provide the patient with distance, intermediate and near vision, thus freeing the patient from reliance on eyeglasses in most cases. He understood that clinical trials had been performed over many years, and he was familiar with the results. His ophthalmologist had not been allowed to enroll Mr. Singh in the clinical trials of the Crystalens because of some corneal dystrophy. Now that this IOL was approved, Mr. Singh wanted to proceed; he had waited patiently for this product and he felt it was the best choice for him.
In the mid 1970s, when I worked as an optician and contact lens technician, I grew fond of my elderly patients who relied on me for some of their eye care. Quickly, I dropped back into those old habits as I interviewed Mr. Singh about his history and vision requirements. I asked if his cataracts hindered him from performing the normal activities of daily living; he told me they did. I asked if new glasses helped; he said not very much. I asked if his ophthalmologist was willing to perform cataract surgery on him; he said yes, but that he was on a waiting list for the Crystalens. It seemed to me that Medicare would almost certainly cover his cataract surgery, but there was a problem.
The dilemma
The Crystalens is a premium IOL with a selling price of $800. Medicare regulations do not allow providers to balance bill beneficiaries for the extra cost associated with deluxe IOLs. In other Medicare regulations, Medicare does permit beneficiaries to select a deluxe frame, deluxe hearing aid or deluxe wheelchair and pay the difference between the purchase price and the Medicare allowable. Regrettably, that is not the case for IOLs. As I described these esoteric rules to Mr. Singh, he was a little disappointed but not deterred. He asked who he should contact at the Centers for Medicare and Medicaid Services to plead his case. I gave him CMSs phone number at their headquarters in Baltimore. I told Mr. Singh that Andy Corley, CEO of eyeonics, and Stuart Cumming, MD, the inventor of the Crystalens, had visited CMS in the fourth quarter of 2003 to inform the agency about the Crystalens. They recommended that the old legacy rules about IOLs be updated to give Medicare beneficiaries the opportunity to choose this new IOL. The manufacturers did not ask CMS to pay for this deluxe IOL, merely permit beneficiaries to do so if they wished. After the meeting, we did not know how CMS would respond, but we hoped that they would appreciate why the old regulations no longer worked.
Stuck in limbo
A few weeks later, Mr. Singh called again. He gave me a list of CMS staffers he had spoken with about his case. Mr. Singhs persistence was admirable, and he clearly understood what he was up against. The staffers had all been generous with their time but not particularly clear about how he might proceed. One staffer had suggested that he sign an Advance Beneficiary Notice (ABN).
At that point, I e-mailed Mr. Singh a copy of Corcoran Consulting Groups Frequently Asked Questions about reimbursement for the Crystalens (Table). I explained that the purpose of an ABN is to inform a beneficiary when a service might not be covered by Medicare and give the beneficiary a chance to choose whether or not to proceed. In Mr. Singhs case, there was little doubt that his cataract surgery would be covered. Mr. Singh volunteered that he was only too happy to pay an additional $650 for the Crystalens he had calculated that Medicare would pay $150 of the cost of the lens, and he would cover the remainder for the IOL. Sadly, I told him Medicares current regulations would not permit his ophthalmologist to accept this commonsense offer. An ABN would not help nothing less than a change of the regulations would fix the problem.
Technical challenges lie ahead for lens refilling
Source: Corcoran Consulting Group |
Not long after this call, I spoke with the billing office manager for Dr. Abraham. This competent individual instantly recognized our mutual acquaintance, Mr. Singh. She confirmed that this special patient was intelligent, persistent, and very well-informed. She also knew that Medicares regulations had boxed him into an untenable position. Mr. Singh could not have the Crystalens because no doctor, hospital or ASC could afford to absorb a financial loss on this premium IOL, and his generous offer to pay for the Crystalens was out of the question. Mr. Singh was stuck in limbo.
Time for change
What can we learn from this true story? Technology almost always advances faster than federal regulations. Certainly, that is the case for the Crystalens.
Interestingly, other third-party payers have no problem allowing their beneficiaries to select the Crystalens and pay for the IOL upgrade. So, Medicare beneficiaries remain on a waiting list for the Crystalens indefinitely, while other patients get the latest technology. So far, the agency has steadfastly refused to change their outdated regulations for IOLs to give Mr. Singh his choice.
Authors note:
Other than the officials at eyeonics, all the names in this account have been changed to protect confidentiality; however, the people described in this article are real, and the story is genuine.
For Your Information:
- Kevin J. Corcoran, COE, CPC, FNAO, is President, Corcoran Consulting Group. He can be reached at 1845 Business Center Dr., Ste. 108, San Bernardino, CA 92408; 800-399-6565; fax: 909-890-1333; e-mail: kcorcoran@corcoranccg.com; Web site: www.corcoranccg.com. Mr. Corcoran is the reimbursement consultant for eyeonics.
- eyeonics, manufacturer of the Crystalens IOL, can be reached at 6 Journey, Ste. 125, Aliso Viejo, CA 92656; 866-393-6642; Web site: www.candcvision.com.