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Managing premium channel costs
Ninth in a series of the top 10 reasons for poor premium IOL outcomes and how to remedy them.
Approximately 10% of cataract surgery within the Medicare system is associated with noncovered services such as a presbyopia-correcting, astigmatism-correcting or toric IOL; laser-guided cataract surgery with intraoperative wavefront aberrometry; and femtosecond laser-assisted cataract surgery. The premium channel involves all of these technologies, including limbal relaxing incisions (LRIs) performed concurrently or subsequent to cataract surgery. To complicate matters, separating the professional component from the facility component for each technology and determining where optometric comanagement fits into the financial puzzle makes one wonder whether the premium channel is even worth it.
CMS rulings
The good news is that two Centers for Medicare and Medicaid Services rulings addressing these concerns for the premium surgeon were approved in 2005 and 2007. The first ruling states: “The beneficiary is responsible for payment of that portion of the facility charge that exceeds the facility charge for insertion of a conventional IOL following cataract surgery. In addition, the beneficiary is responsible for the payment of facility charges for resources required for fitting and visual acuity testing of a presbyopia-correcting IOL that exceeds the facility charges for resources furnished for a conventional IOL after cataract surgery.” The 2007 ruling applies similar language with regard to toric IOLs.
“Visual acuity testing” essentially is considered to be intraoperative wavefront aberrometry, with the beneficiary financially responsible for this technology as long as it is an accepted option prior to cataract surgery on the appropriate Advanced Beneficiary Notice of Noncoverage (ABN) form signed by the patient. ABN forms must also be obtained for presbyopia-correcting IOLs, toric IOLs, and LRIs (manual or femto-driven). ABN forms apply to Medicare patients undergoing these premium technology procedures as noncovered services. If a patient is covered under a plan other than Medicare, then ABN forms should also be obtained; however, some third-party payers may cover these technologies, necessitating a refund for patients in this scenario. In the end, appropriate legal and professional health care consulting advice should be obtained prior to embarking on the premium channel of financial reimbursement.
Mitchell A. Jackson
Once the financial legal maze is clarified for a particular practice setting, then the premium surgeon needs to determine the best pricing model to cover the chair time and product costs for these advanced technologies while remaining profitable at the end of the day. There have been various successful models, from a la carte to comprehensive packaging to product- or outcome-driven tiers presented to patients. The strategy that I have delivered with success is an outcome-driven three-choice plan with an all-inclusive package for each choice based on the appropriate CMS approved rulings and ABN authorizations (with estimated costs listed) for each noncovered service to be offered.
Three options
Our first option is the standard plan, covering phacoemulsification, a standard aspheric IOL, and no correction of astigmatism or intraoperative wavefront measurement, essentially guaranteeing a visual outcome requiring glasses full time for distance, intermediate and near visual task needs. Our second option is our “driving” plan, covering phacoemulsification, laser-guided intraoperative wavefront aberrometry, and toric IOL and/or LRIs for astigmatism correction, providing a visual outcome needed for legal driving and distance tasks only and ensuring the need for some form of prescription reading glasses or contact lenses for intermediate and near vision tasks. Lastly, our third option is our “forever young” plan, providing phacoemulsification, laser-guided intraoperative wavefront aberrometry, and a presbyopic-correcting IOL and possible LRIs for the full gamut of visual correction, covering approximately 80% of all daily visual tasks.
We never offer more than two options to a patient (ie, standard or driving, standard or forever young) to prevent patient confusion, which often leads to no surgical decision at all. We also perform a full comprehensive preoperative evaluation, including corneal topography, Marco OPD-Scan III readings for mesopic and scotopic pupil size, spherical aberration, angle kappa, delineation of corneal vs. lenticular astigmatism, and OCT measurement of the macula to rule out preop macular pathology such as epiretinal membrane or macular holes. And we leave plenty of chair time for setting patients’ expectations preoperatively. Patients who do not qualify for premium technology will sign a waiver indicating their understanding that they have pre-existent pathology (eg, diabetic retinal disease, advanced age-related macular degeneration or full-thickness macular holes) that will preclude them from such premium technology. Our office and ASC have not entered the femtosecond laser-assisted arena yet, but much like intraoperative wavefront aberrometry, the femto technology will be dropped into one of our two premium options with a price adjustment to maintain profitability and appropriate compliance based on the CMS rulings in place today.
In the end, keeping choices simple and stratified with an outcome-driven approach that a patient can identify with has yielded the most efficient and highest conversion rate we have achieved to date. It helps that many of my cataract patients have undergone previous refractive surgery, making the premium transition much easier for them based on their desired outcomes. As new premium technologies are approved, I can drop them into the appropriate outcome category described above to drive patient conversions to support their outcome improvement rather than sell the brand of the product, which most patients have no knowledge about anyway.
Stay tuned for my 10th and final article in this series of how to remedy the top 10 problems in the modern world of premium cataract surgery.