Communicating Unreimbursed Fees Associated With the Crystalens HD

Discussing the costs and benefits of premium IOLs with staff and patients is imperative for success.

By Jay S. Pepose, MD, PhD

In 2005, the Center for Medicare and Medicaid Services (CMS) issued a ruling, stating that the presbyopia-correcting functionality of an IOL doesn't fall into the benefits category, and therefore isn't covered, along with provider or physician services required to insert a presbyopia-correcting IOL or monitor a patient receiving a presbyopia-correcting IOL.

With this mandate, for the first time in ophthalmology, the physician can bill for the difference in cost of a premium IOL over a standard monofocal IOL and the additional services associated with implantation and postoperative management. This change created a true paradigm shift for patients, physicians and staff. While patients anticipated incurring out-of-pocket expenses when going to the dentist for a crown or bridge, they were accustomed to nearly carte blanche coverage when their physician wasn't performing cosmetic surgery. Because of this fairly recent change in policy, it's not unusual to encounter patients who express dismay when they learn that Medicare won't fully cover the costs of services and products associated with premium lens implantation.

However, thanks to the availability of long-term, no-interest financing, patients can better afford the cost of the Crystalens HD and fit it into their monthly budgets. In my practice, we offer the services of Care Credit. Patients can quickly determine their eligibility online in a matter of minutes.

This article will review the importance of educating staff and patients about the out-of-pocket costs associated with premium IOLs, the inherent benefits of IOLs and strategies to communicate the surgical process to patients.

Communication Challenge

Whether or not patients are eligible for long-term financing, ophthalmologists are presented with the challenge of effectively educating patients and staff about the value of the additional services and benefits associated with premium-IOL implantation. For example, a cataract evaluation for presbyopia-correcting IOLs requires additional tests to determine a patient's candidacy for laser vision correction, since this may be required postoperatively to achieve the desired visual outcome. The surgeon needs to assess corneal topography (not just keratometry), regional pachymetry, dry eye status, risks for developing ectasia, in addition to the standard cataract evaluation. Biometric testing may be more extensive.

Since postoperative enhancements are generally delayed 90 days or longer to allow for possible refractive effects of healing, the length of time allotted for covered post-op services is longer than the customary 90-day window Medicare provides. Physicians must make patients aware of these additional services and benefits associated with their out-ofpocket expenses. It's best to discuss these issues and put them in writing. Sometimes the staff isn't fully aware of these additional services, the amount of chair time involved or the details of postoperative coverage. If staff members don't appreciate the added value and cost of providing these services, they could subliminally convey their uneasiness to patients and inadvertently undermine a refractive IOL practice. So staff education is as important as patient education.

Benefits of Premium IOLs

Quality of life and quality of vision surveys attest to the benefits of the Crystalens.^1,2 There's a delicate balance between conveying the improvement in depth of field associated with the Crystalens HD without creating unreasonable or unachievable expectations. It's important to explain to patients that the Crystalens HD provides better enhanced near vision and depth of field than monofocal IOLs and isn't associated with increased photic phenomenon or decreased contrast sensitivity seen in some patients who have multifocal IOLs. However, because it's a man-made lens, it doesn't compare with the form and function of the natural crystalline lens we had when we were 20-years-old. More appropriately, physicians should compare the Crystalens HD to alternative, existing IOL technology, not the natural lens in youth. My staff emphasizes that choosing a particular IOL is a once-in-a-lifetime opportunity, and in these times of economic uncertainty, what better investment is there than in yourself? As Shareef Mahdavi, MD, once asked, "What other purchase can you make, which you'll use 16 hours a day, every day for the rest of your life?"

Avoiding Unwanted Surprises

Patients implanted with the Crystalens, like any other premium IOL, may require Nd:YAG laser capsulotomy or postoperative laser vision enhancement. It's important to discuss these possibilities before cataract surgery, so patients don't view the development of posterior capsular fibrosis as a failure of the IOL procedure. Some surgeons roll the cost of potential laser vision enhancement into their global fee, while others charge an additional surgical fee or limit it to a facility fee. I recommend physicians discuss any potential additional costs preoperatively and have patients sign a written document outlining all potential fees. Ask your staff to make a copy of the document to give to the patient and keep a copy in the office medical records, so there's no miscommunication.

Change is the Only Constant

I often tell my staff that the only thing one should count on is change. Yet, change can be quite painful — for patients who have become accustomed to Medicare benefits that have been established for many years and for nonrefractive surgery practices that aren't used to asking patients for out-of-pocket expenses for unreimbursed products and services. I anticipate that the premium IOL model of patients paying for upgraded services could become more prevalent in other aspects of ophthalmology and the medical profession in general. We need to embrace this change in our practices and facilitate it with effective communication. OM

References

1. Pepose JS, Qazi MA, Davies J, et al. Visual performance of patients with bilateral vs combination Crystalens, ReZoom, and ReSTOR intraocular lens implants. Am J Ophthalmol. 2007;144:347–357.
2. Cumming JS, Colvard DM, Dell SJ, et al. Clinical evaluation of the Crystalens AT-45 accommodating intraocular lens: results of the U.S. Food and Drug Administration clinical trial. J Cataract Refract Surg. 2006;32:812–825.