Develop practice implementation strategy for integration of new retinal therapies
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SAN FRANCISCO — It is important for ophthalmologists to understand FDA indications and develop a proper practice implementation strategy for new retinal drugs entering the market, according to a speaker here.
“In terms of reimbursement, we know that there are many challenges. The challenges for procedure reimbursement are that these are usually determined by CMS with [RVS Update Committee, RUC] input, and you have reevaluations by CMS, CPT or RUC-initiated [review of codes],” Ankoor R. Shah, MD, said at Retina Subspecialty Day at the American Academy of Ophthalmology meeting.
Shah described useful implementation practices for newer FDA-approved retinal drugs, including Eylea HD (aflibercept 8 mg, Regeneron), Vabysmo (faricimab, Genentech), Izervay (avacincaptad pegol intravitreal solution, Iveric Bio), Syfovre (pegcetacoplan injection, Apellis Pharmaceuticals) and Xipere (triamcinolone acetonide injectable suspension, Bausch + Lomb). Physicians should determine if a drug is appropriate for their patient, align their electronic health records and preset templates to make sure they match with the drug, and update consent forms to successfully integrate new retinal therapies, he said. The next step in the process is to consider a phased implementation.
“In the case of dry AMD, you may want to start with the easiest cases first — straight dry AMD patients who have GA, then maybe patients who have wet in one eye and dry in the other eye so that your payments are not kicking back the payment for wet treatment,” he said.
Retina specialists should follow their claims and be prepared to appeal if necessary, particularly in cases in which permanent J-codes or Q-codes are not present. Utilizing patient assistance programs can also be helpful, Shah said, as they can help mitigate reimbursement risk and reduce patient financial burden.
Finally, Shah said, physicians should monitor payer policies.
“These can be things like, even if you get paid in the beginning, make sure you monitor for it in the future,” he said. “Monitor for frequency edits. ... Monitor for additional requirements.”
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Shah AR. Reimbursements of new retinal drugs. Presented at: American Academy of Ophthalmology meeting; Nov. 3-6, 2023; San Francisco.
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