Relationship with surgeon vital to effective cataract surgery comanagement

ROUND TABLE PARTICIPANTS
Thomas Ballard, OD, is in group private practice in two offices in Dallas. He is also the Southwest regional director of LExES, a national lasar surgery comanagement company.	Walter L. Chaote, Jr., OD, FAAO, has been in private practice in Nashville, TN, since 1979, specializing in contact lenses and refractive surgery comanagement. He is a member of the Editorial Board of Primary Care Optometry News.	Arthur A. Medina, Jr., OD, has been in private optometric practice in San Antonio, TX, since 1983. He practiced for 10 years in an ophthalmological practice, with a 2-year ophthalmological disease fellowship. Dr. Medina is a member of the Editorial Board of Primary Care Optometry News.

John A. McCall, Jr., OD, has practiced with his father is Crockett, TX, for 22 years and has been comanaging cataract patients for 21 years. He is an active staff member of East Texas Medical Center of Crockett. Dr. McCall is a member of the Editorial Board of Primary Care Optometry Newsand this month will complete his term as president of the American Optometric Association.

Robert Prouty, OD, FAAO, is the center director of Omni Eye Specialists, a multispecialty referral/comanagement center in Denver. He lectures extensively across the country and has published numerous articles in various journals and international publications. He is residency-trained in ocular disease.

Arthur A. Medina Jr., OD: Comanagement has been a well-established, well-documented system of treating patients throughout the history of medicine, and it’s simply the cooperation between two specialties or subspecialties to care for a particular patient’s needs.

Medicare has significantly cut back surgical reimbursement while it has increased reimbursement for general medical services.

Additionally, some states are disputing or frowning upon comanagement, specifically targeting optometric/ophthalmologic comanagement as not being in the best interest of the patient. This is very important, because we, as providers, are always trying to do what is in the best interest of the patient. We’re not doing this for marketing purposes. What is in the best interest of the patient is for the primary care provider to make the initial diagnosis and select the most competent surgeon to ensure the best outcomes. Keeping that in mind, is anyone here actively marketing toward the geriatric patient population?

John A. McCall Jr., OD: In 1978, I couldn’t find anyone else who was comanaging, so we formulated our own plan. A Canadian ophthalmologist was with us for about 6 years, and when he left, I was convinced that it was good for patients to have the surgery done at our hospital and for us to be able to take care of that. At that point, I approached Robert Lehmann, MD. He and I have been comanaging patients for about 15 years. I have provided 1-day postoperative follow-up for all of that time. We have seen between 4,000 and 5,000 patients at 1-day postop. We also have a telemedicine system where we have the ability to send images back and forth between the offices, which is of great help.

Our practice has evolved into a geriatric practice without us doing any marketing. In 1986, I was trying to de-emphasize geriatric care in my practice because we were not getting reimbursement from Medicare for comanaging cataract surgery patients, nor for diagnostic testing such as visual fields, A-scans and B-scans. Shortly thereafter, the American Optometric Association was successful in securing Medicare reimbursement for optometrists. Since then, we haven’t looked back. The only marketing we have done is a screening at the senior citizens’ center every 6 months.

Robert Prouty, OD, FAAO: Our clinic is founded on the concept of working with optometrists in a comanagement situation. We work with primary care physicians and optometrists. We see only patients who are referred by optometrists or physicians.

Colorado is the only state that has postoperative provisions for comanagement in our optometric bill. The way we market to our patients is to work with doctors who have the best interests of their patients in mind. After patients are referred to us, we provide good quality care. Good quality surgeons and good quality outcomes work efficiently for the patient, the referring doctor and, we hope, for us. That type of word-of-mouth goodwill, the good quality results and patients being able to stay with their local doctors flies in the face of this idea that it’s fee splitting and not in the best interest of the patient. Quite the converse is true.

Walter L. Choate Jr., OD, FAAO: We have a very large multifocal contact lens practice, and, with the aging of the population, I have seen our geriatric patient base grow substantially. Also, demographically, our market area has a high concentration of retirees.

In terms of internal marketing efforts, we have a message on our hold system that describes the benefits of clear cornea and cataract extraction. It also describes our relationship with our consultative surgeon. We also send out quarterly newsletters. We do selective mailings as new and innovative presbyopic products come out. We do screenings in most of the assisted-living facilities throughout the year. In terms of marketing our services to patients regarding comanagement, we are always careful to explain the options, and it’s always the patient’s choice to enter into a comanagement relationship. Rarely does someone not want to take part in comanagement.

Thomas Ballard, OD: We do not specifically market to the geriatric population, but we do circulate newsletters that explain our comanagement possibilities. We have an assisted-care facility within a mile of us, and we have become the doctors on staff of that facility.

Beginning a comanagement relationship

Dr. Medina: Just as I would have expected, you have all taken the proactive approach and have already coordinated your efforts to provide surgical care for your patients. What can you recommend to colleagues regarding establishing a coordinated, cooperative, comanagement arrangement?

Dr. McCall: Many of our colleagues would like to be involved in comanagement, but may not be close enough to a referral center or may not have a relationship with an ophthalmologist. I could not imagine myself not being able to find an ophthalmologist somewhere in the referral area with whom I could sit down and talk.

If someone does not have a relationship with an ophthalmologist in his or her hometown, he or she could probably go as far as 60 miles away. An hour’s drive is not too far at all to establish that type of relationship. As long as it’s approached with mutually beneficial criteria for both doctors and the patient, I think it’s possible anywhere in the United States.

Dr. Prouty: Frankly, I feel the doctor starts the ball rolling by developing and exploring this relationship with his or her surgeon of choice. Both doctors should discuss how the two practices can act in concert to give the best quality care. Then, they can proceed with talking with their patients.

The last thing you want to do is think that you have a relationship with a prospective surgeon, send a patient to him or her and have it blow up in your face. If that happens too many times, you’re no longer interested in developing that relationship.

There are pockets in Colorado, for instance, where things are relatively provincial, and those ophthalmologists don’t want to work with the local optometrists. So, it does take some effort, but I think it’s rewarding to the practice and the patient when those relationships can be retained.

Dr. Choate: I agree that it’s important to establish a good communication plan with the surgeon. And along those lines, it is important for the optometrist to become very astute about the mechanics of cataract surgery, the various types of IOLs and the many complications that can arise both intraoperatively and postoperatively.

The OD should take it upon himself or herself to spend some time in the operating room as well as initially providing 24-hour postops with the attending surgeon. Set up some quality communication systems, such as forms to be used or a video exchange.

When deciding which doctor will do what, I think it should be done gradually according to the doctor’s skills. With today’s clear-cornea cataract procedures, the complication rate is very low. However, if the doctor is not accustomed to comanagement, he or she should take over duties gradually.

I’m lucky to practice in a metropolitan area that has a lot of ophthalmic subspecialties. I’ve built very strong bridges with many ophthalmic surgeons because we refer for specific disease entities. I’m careful to be specific in referring to pediatric ophthalmology or oculoplastics or retina-vitreous sub-specialists. As a result, we have a network of doctors who refer back and forth quite comfortably.

When I first started my practice in the early 1980s, there was a group of ocular surgeons who would not accept referrals from optometrists. Patients had to go through a general ophthalmologist first. That’s when I began thinking that I’m going to be specific and not be shotgunning these patients.

Dr. Ballard: Because I, too, practice in a metropolitan area with many referral sources, we have had a fine array of choices to go to for all the other subspecialties. The first thing you should do is find that surgeon — and it may not be just one — with whom you are comfortable. Then, tell him or her what you can do and at what level you would like to participate. To take it to the next step, go spend time at the surgery center.

It's invaluable for ophthalmologists to see what level of care you provide and that you have an understanding of what each specialty does. Over time, both sides become more comfortable with what the other is doing.

There should be consistency in communication, such as expecting to get a fax on the day after the procedure. Many times, I will get a phone call from the surgeon immediately post-procedure or post-visit. Sometimes, we'll discuss it on the phone with the patient still in the room.

Selecting a surgeon

Dr. Medina: What criteria do you have for selecting a surgeon? Do you encourage your staff to become more familiar with the surgeon’s staff for the purpose of coordinating that transfer of responsibilities and helping the patient?

Dr. McCall: The criteria that I go by now are the same criteria that we drew up in 1978. We sat down with the ophthalmologists and actually spelled out what we do and what they do. To get along, you must have a clear understanding of this. We do optometry. We do primary care. They do the specialized and surgical care.

I have seen some of my colleagues let ophthalmologists come into the practice and take it over. I firmly believe that this is the optometrist’s practice and that the control should be with the optometrist. Certainly, any diagnostic test that the ophthalmologist needs to do is within his or her professional judgment. But allowing the ophthalmologist to do optometry is where you need to draw the line. Lines need to be drawn to where you both have a comfort level.

Maintaining the relationship

Dr. Medina: How do you maintain your relationships with comanaging surgeons?

Dr. McCall: I am 60 miles away from our cataract surgeon, and he has approximately five other optometrists referring to him. Once every 6 months, we all sit down together. The ophthalmologist usually hosts a dinner for us. Our referrals are a huge portion of his practice, and he's very interested in any criticisms we may have. We discuss complications that we see.

We all get along so well. This has evolved into not only a partnership but true friendship with everybody in the room. So everyone takes the criticisms constructively.

Dr. Prouty: We have done everything that you mentioned. We have set up our comanagement practice as an extension of the optometric practice in our office. Our patients are counseled by our pre-surgical coordinators with a signed release that says that they have the option at any time to have their postoperative care provided by the surgeon’s practice or the optometric practice. However, we tell them that it is anticipated that they will be seeing the optometrist as per their design and request.

As long as patients have options and education, they see the benefits of comanagement. Many patients have expressed to us that they feel like they not only sustain their optometrist, but they gain another level of care in case the optometrist can’t respond for some reason. They have another number they can call with confidence, and they feel it has enhanced their care.

We have implemented a major continuing education program at our center. Ten months out of the year, we do education for the optometric and primary care physician network.

Patients know they are going to get the best quality surgery and that their optometrists will direct them to the right people to achieve that.

Dr. Medina: It sounds like you’re recommending that primary care providers never be a barrier to secondary or tertiary care, but actually a facilitator when indicated. I think that is such an important ingredient to successful comanagement.

Dr. Prouty: They don’t need to become friends, but the working relationship lets you become friends. The real goal is to give the best quality care to the patient, and you will achieve those other things as well.

Dr. Choate: Optometrists who are not in comanagement relationships need to get into the operating room and see the surgeons’ demeanor pre- and postoperatively as well as evaluate the surgeon’s skills. They also need to look at surgical skill.

Sometimes, your comanaging ophthalmologist may not be part of your patient’s insurance plan. If I have not been to surgery with an ophthalmologist and I have never seen his or her patients postop, I generally will not recommend that surgeon.

The surgeon with whom I work prefers to do the 24-hour postops right now. That’s not a problem for me. The surgeon with whom I’m working trained at Louisiana State University. He has urged me to help him develop protocols with other optometrists in the area so that he better understands where they’re coming from. He doesn’t want to get into either a refractive surgery or a cataract surgery relationship in which the OD is collecting a fee and really not doing the total work. That is the key.

We must do business with people who are after the best care for our patients. Period.

Dr. Medina: Again, it is important to facilitate when indicated rather than being a barrier.

Dr. Prouty: Another major cog in the wheel is the interaction and communication between the optometrist and the ophthalmologist. Our optometrists send us a postoperative report on every postoperative visit. We review it and keep it on the computer to assess the outcomes of these patients.

This is a standardized form. The 1-day postop form is faxed to the OD the day the patient is seen. This is done in case there is a complication. With good communication, everyone is on the same page. It is a real hand-in-hand type of thing.

Dr. Ballard: During our first few years of comanagement, we had set amounts of time we spent in the surgery center each year. That was part of our continuing education.

Dr. Medina: In our comanagement relationship, we have an annual state of secondary and tertiary care report. The optometrists conduct a meeting to report the surgeon’s results and complication rate to him. This is our opportunity to give outcomes analysis.

Dr. McCall: I think that is an excellent idea. With our large geriatric population, we see a lot of age-related macular degeneration. When we assess outcomes, we try to have a realistic expectation. We really go all out trying to get a good view of that fundus and trying to present a realistic outlook to that patient.

We have worked with the same surgeon for about 15 years, and he has excellent outcomes. The only ones that didn’t turn out really well were due to some retinal problems.

Dr. Prouty: We’ve done outcomes analyses, but I’ve never asked the optometrists for their own practice’s outcomes analyses. I’m sure some are doing it.

We’re seeing the outcomes, but it’s the same inferential stuff. We all think our outcomes are great, but what percentage of patients has cystoid macular edema from your surgeon? Is your loss of a contact lens case because of something that happened in your office?

Dr. Medina: In this era of managed care, with ODs obtaining optometric owned and controlled contracts, we’re able to sit in front of the purchaser of managed care and say that our diabetic patients have fundus photography and photodocumentation on an annual basis. We all have an internal standard, but nothing can substitute for outcomes documentation.

Dr. Prouty: I hired a consultant, and it took 3 days of chart review to come up with that data. It still wasn’t the degree of outcomes we’re looking for.

Dr. Choate: The optometric comanagement centers typically have some pretty sophisticated outcome analysis systems; however, since most of the data reported comes from the comanaging doctors, standardization can be difficult. But I do think it’s valuable.

Dr. Ballard: We could certainly be better at knowing exactly what our outcomes are. Our network has regular meetings to discuss a whole array of topics, including surgical care and anecdotal stories. However, we don’t have the statistics at our fingertips.

Obtaining Medicare reimbursement

Dr. Medina: What about the business aspect of getting reimbursed for what you do? What you have instituted in your practice, in your business plan, to ensure that your surgeon has applied the appropriate modifiers, so when you submit for reimbursement you are being reimbursed at the most appropriate levels?

Dr. McCall: We are hooked up, as most practices are, with electronic billing with Medicare. Because we routinely do the 24-hour postop visit, we routinely file for the whole 90 days, which is 20% of the comanagement fee. When one falls through the cracks, it actually is usually caught by Medicare. They will deduct from the surgeon, and you have to re-file with a new modifier to actually subtract from that.

We have very little of that, because this has been done so routinely and for so long by our practice. My instructions to our office manager are to always make sure that we’re on the same page regarding what day we took over care for the patient. That is critical. Our office manager talks to the surgeon’s office manager, who officially gives a release date.

Dr. Prouty: We work the same way. If there is a complication, we sustain the patient care with a surgeon.

When we call and tell the primary care OD that there is a complication and we feel it would be in the best interest of the patient for care to be sustained by the surgeon, I’ve never had a problem from the primary care optometrist. This is really an issue of trust. Of course, they want the best for their patients.

Dr. Medina: How do you help facilitate that primary care provider’s office being reimbursed? Has there ever been an instance when you have detected that the primary care provider is not being reimbursed at the highest rate? How do you assist them?

Dr. Prouty: Miscoding happens. In our system, when the patient is scheduled for surgery, that chart goes through our billing coordinator before it goes anywhere else to ensure that the patient’s insurance program will allow working with an optometrist and it is not a “captured” managed care program, where the postoperative care must be accomplished at our office because the OD is not a panel provider. We do some of our postoperative management ourselves by contract because of the managed care environment.

If the patient cannot go back to the OD, we notify the doctor that, due to insurance constraints, we’ll sustain the patient’s postop care. The patient will be returned to the OD when the postoperative period is up.

Before our surgeons see their patients 1-day postop, the system is already in place to ensure that the patient’s interests, the optometrist’s interests and the surgeon’s interests are all being met equally.

Dr. Ballard: Our surgeons send a fax to specify what day they’re releasing care. This way, we know exactly how many days we’re filing for and how many days they’re filing for.

Dr. Medina: What are other tricks of the trade if you get an EOMB [explanation of medical benefits] that has not reimbursed you at the rate you thought you should be reimbursed? What tactics do you use in your office to pursue what you feel is an appropriate reimbursement?

Dr. McCall: Because my office manager does this for me, I am as much a neophyte as any of the readers. I don’t know how she does it, but she always gets me reimbursed.

Dr. Medina: Do you really not get at all involved with failed reimbursements? Do you know what percentage those are? Do you have any of those data?

Dr. McCall: Only when my office manager sees it fit to tell me.

Dr. Choate: My insurance coordinator pretty much takes care of that. Usually, if you don’t get paid the proper amount, it’s because of a coding error.

Occasionally, we call ahead of time and get pre-certification to comanage a patient. Then we provide virtually 90 days’ worth of postoperative care and get paid nothing. The MD gets paid the entire amount, and then we find out that the insurance company doesn’t pay for optometric comanagement. When that happens, there’s not a whole lot you can do about it.

Dr. Ballard: We have a pretty strong line of communication between the billing coordinator at the surgeon’s office and our billing coordinator. The surgeon’s office is very good about helping us.

Dr. Medina: As you know, the typical secondary and tertiary care provider’s practice is dependent upon third-party reimbursement. That’s not typically the situation in the normal optometric office. It’s somewhat of a new arena within the optometric practice to have the resources to get reimbursed by third-party payers. Do you ever use the surgeon’s business office to assist you to get reimbursed?

Dr. Choate: No.

Dr. McCall: No, we never have. We’ve always been able to do that ourselves. There have been times when a surgeon did not code for the follow-up care when we, in fact, provided the follow-up care. There is a code you can file to have that deducted from that surgeon. You need to have a relationship, or you’ll have a discussion over this.

The first time this happened, it brought them under a little scrutiny, because Medicare called them to tell them they had made a mistake. Then, the surgeon called me to find out how to alleviate the problem. That rarely happens.

Dr. Prouty: We have many optometrists who call my billing coordinator for help with getting paid. Without my billing coordinator, I would be lost. Frankly, the ODs in the area would be lost, too. When optometrists hire someone new for their billing office, he or she will come spend a day with our billing coordinator.

We have actively participated with the ODs in the area to bring up that level of sophistication of the billing office.

Dr. Medina: Haven’t you found that communication between staff does nothing more than fortify that OD/MD relationship?

Dr. Prouty: Of course. They speak the same language, and they understand what’s going on. In fact, they start to communicate amongst themselves if somebody picks up a new code. So it just makes this a more cohesive extension and enhances care.

Dr. Ballard: Our network originally was very reliant on the surgeon’s billing coordinator, who has been there for a long time. We know her and she knows us, and we go back and forth quite a bit. Now, as we’ve gotten better at it, those calls are fewer. Early on, there was a lot of communication.

Dr. Medina: Any final comments?

Dr. Prouty: Comanagement, for optometry, has become an old, favorite pair of slippers, and we’ve gotten accustomed to them. However, it is something we can lose easily. Make sure that comanagement is working for the best of our patients and for the practice. Continue to foster it and take care of it. It has really moved optometry forward. It has assisted us in offering and delivering the best quality of care for our patients.

Dr. Choate: In the 1970s and early 1980s, optometric comanagement centers were the leaders in providing a framework upon which to build a comanagement relationship. It is much more difficult to do that with independent ophthalmology because there is inevitably some primary care overlap.

If a patient needs to be in the care of the surgeon for a few weeks longer and it’s in the patient’s best interest, that’s what we’re in the business of providing. Our challenge is to more formally structure the independent relationships, much the same as optometric referral centers have done. With a little work, proper systems can be established.

Dr. Ballard: It seems to boil down to a level of trust. If you trust the surgeon not to steal that patient or to steal referrals, the relationship really seems to work well. Then you don’t worry about peripheral issues, because you’re focused on what is best for the patient.

Dr. Choate: No one can steal a patient you’ve taken good care of.

For Your Information:

• Thomas Ballard, OD, can be reached at 12700 Preston Rd. #100, Dallas, TX 75230; (972) 960-2020; fax: (972) 960-2063; Tballard@flashnet.com.
• Walter L. Choate Jr., OD, FAAO, can be reached at 607 Due West Ave., Suite 111, Madison, TN 37115; (615) 868-4262; fax: (615) 860-2016; e-mail: WChoate1@aol.com.
• John A. McCall Jr., OD, can be reached at 711 East Goliad Ave., Crockett, TX 75835, (409) 544-3763, fax: (409) 544-7894; e-mail: AmOptBDJAM@aol.com.
• Arthur A. Medina Jr., OD, can be reached at 1110 McCullough, San Antonio, TX 78212, (210) 225-4141; fax: (210) 229-9400; e-mail: artmedina@aol.com.
• Robert Prouty, OD, FAAO, can be reached at Omni Eye Specialists, 55 Madison, Ste. 355, Denver, CO 80206; (303) 377-2020, fax: (303) 377-2022.