Taking on Premium IOLs

How to integrate your patients' high expectations with the new billing considerations.

Mr. Sheppard: Premium IOLs brought new and exciting options for patients and practitioners, but they also brought new challenges. Let's talk about their impact in terms of patient expectations and education, as well as any billing landmines we should watch out for as ASC managers.

Calculating Fees

Mr. Sheppard: Premium IOLs require staff time and some different uses of physician time. How complicated is this in terms of billing?

Ms. Steigerwald: IOLs have changed a lot for ophthalmology and the ASCs because of the additional charges and how they're handled. There is a standard allowance for an IOL in the surgical charge. Too many times, as I look at surgical charges from both ASCs and hospitals, I don't see that allowance reflected anywhere. I'm concerned that ASCs and hospitals will get into trouble for making it look as if the patient has paid for something that Medicare also paid. That charge really needs to be shown.

I've also been surprised by the number of people who think they can't add a handling charge to the ASC fees for IOLs. Of course you can! Premium IOLs require additional handling and administrative costs, and you need to pass along that cost. These lenses are great for patients —I'd love to trade my glasses for a pair — and they're profitable. It's a win-win.

Ms. Acker: They're great lenses, and they'll be great for the ASC. They have some disadvantages for us in the ASC, so we're working to minimize those disadvantages and make the process go more smoothly. For example, if our surgeon is out of the OR marking the eye and checking the axis, that makes our days longer and our staff costs higher. So, we've started training some of our post anesthesia care unit nurses to do the marking under the doctor's direction, and I think that will save some time.

Today, it would be nearly impossible to incorporate pre-op visits into the routine, so I think [that's] the best idea: Give patients a tour of the facility from their living rooms. They see who you are and what your facility looks like. — Barbara Ann Harmer, R.N., B.S.N., M.H.A.

Ms. Steigerwald: I suggest that you carefully factor these things into your handling fee: the extra OR time, the extra administrative time and so on. Practices need to take all of these things into consideration when they determine the handling fee. People often focus on the OR time and forget the time that everyone else in the clinic spends on a case.

Mr. Sheffler: Regarding handling fees, I find that some doctors set up a separate appointment for the patient's A-scan and then talk to the patient about refractive lenses during that appointment. Because of this, they make their lens orders very late, incurring rush shipping charges, which need to be accounted for in the handling fee as well.

Shaping Expectations

Mr. Sheppard: We often talk about enhancing the patient's experience during the surgical encounter and meeting high expectations. People are paying out of pocket for premium IOLs. Many of these patients are baby boomers, who are educated, informed and very demanding. We can't handle the full education and setting of expectations in the ASC. If patients arrive for surgery at the ASC not understanding what they're buying or what's going to happen to them, we have a problem.

Ms. Harmer: You're right on the mark. Patients also need to know — before they ever come to the facility — what to expect postoperatively. That's where many ASCs go wrong. It's the facility's responsibility to give patients their postoperative or post-procedural instructions — that shouldn't be done at the end of the procedure but at the time of preoperative preparation.

Ms. Acker: I agree. When instructions are given immediately after surgery, patients don't remember much. To better educate patients in our practice, we send each cataract patient a booklet that explains the experience beforehand. We also give patients a list of frequently asked questions. We have a preadmission testing nurse set up the appointments, and the nurse always asks, "Do you have questions?" We're also producing a DVD to introduce patients to our facility. Next, we'll be looking at scripting what our staff members tell patients, so that all patients get consistent instructions and consistent answers to their questions.

Ms. Harmer: Today, it would be nearly impossible to incorporate pre-op visits into the routine, so I think you have the best idea: Give patients a tour of the facility from their living rooms. They see who you are and what your facility looks like. They hear what you'll do for them, what you expect and what they should expect. That's wonderful.

Ms. Steigerwald: Speaking as a former patient, I can tell you that there are things patients don't want to see, and this raises an interesting point about deciding how much to tell your patients.

Ms. Acker: Some patients want to know everything, and some patients want to know nothing. It's up to us as nurses and educators to make that assessment. I ask myself, what does this patient really want to know? And I'm ready with an array of thorough answers to every possible question. Some want those very thorough answers; they want me to tell them on a cellular level what's going to happen. Others say, "Don't tell me about it. Just do it." I think the best way to handle this disparity is to give all patients an opportunity to learn what they want to know. We can inform them by using good publications and prepared scripts for patient education.

Strengthening Informed Consent

Mr. Sheppard: The education process that begins with literature or a DVD leads to a short visit to the ASC before surgery. How does the patient enter the ASC? Is the IOL selected? Is the patient fully informed?

Ms. Steigerwald: I believe the IOL should be selected before the patient arrives at the surgery center, because the informed consent process requires planning and time. For surgical procedures, informed consent means you've explained every option possible. If you haven't, there's a liability risk. Most practices have more time to spend and should be responsible for the informed consent. We can't order a lens or prepare a bill if we don't know what lens the patient wants, and they should know that coming in.

Mr. Brown: I think physicians would like some help with that as well. Physicians are comfortable discussing clinical outcomes, but they don't go to school to say, "This device is really great, and it costs this much." Despite all of the press about the new premium IOLs, most patients come into our practice with no knowledge of the technology that's available to them.

Ms. Steigerwald: I've looked at this from the patient's point of view, going into surgery, and the experience can be very frightening. Surgery isn't an everyday occurrence for patients — only for the professionals who perform it or assist. That's something to take into consideration as part of this discussion. You don't want to add to the anxiety. The patient has to sign his consent form, confirming that he's read and understands the procedure. Patients can't be comfortable signing that based on the 3 minutes a physician or nurse spends with them on the day of surgery. This puts the responsibility on the organization and the practitioner to obtain informed consent.

Paying for Premium Lenses

Mr. Sheppard: What other administrative considerations come with premium IOLs?

Ms. Acker: We need extra time to organize payment from these patients. They have to pay for the lens at the front door, and that takes more time.

Ms. Steigerwald: First, I'd say that the time you spend collecting the check should go into your handling fee. Alternatively, many practices have had success having the patient write the physician's check and the ASC's check at the same time, so all fees are paid in advance.

Mr. Sheppard: I want to emphasize a key point here: There must be two separate checks.

Ms. Harmer: Yes, they need to write two separate checks to keep everything very clear.

Mr. Brown: That's exactly how we handle it, in advance, through our surgery schedulers and financial counselors. The counselors go through the explanations and answer the patients' questions about what they're paying. We've found that payment processing works much better this way, because we have the time to do this in the practice, but we don't have time to do it in the ASC.

In my opinion, the last thing you want to ask a patient to do on the day of his surgery is write a large check or have anxiety about money. We want to minimize their stress and get them through surgery and on to recovery. We want them to start enjoying their new, high-tech IOLs as soon as possible. OM