Quick Hits

CMS takes aim at ‘recalcitrant providers’

Habitual overchargers face fines and expulsion.

By René Luthe, Senior Associate Editor

Physicians whom the CMS deems to have a pattern of billing for medically unnecessary services and charging excessive fees — even after extensive training to remedy such behaviors — will find themselves targeted for civil fines and possible expulsion from Medicare as part of a new initiative to combat Medicare abuse.

In a CMS directive issued in January, the agency offered a new means of policing what it terms “recalcitrant providers” suspected of abusive billing practices. Medicare administrative contractors are to report such providers to CMS, which would turn them over to the Office of the Inspector General (OIG) in the Department of Health and Human Services (HHS). The OIG would have the power to fine these providers, exclude them from Medicare or do both.

CMS defines “recalcitrant providers” eligible for targeting as those who “abuse” Medicare despite remedial education; the agency cites two particular kinds of abuse federal law addresses. One is submitting claims for a pattern of services or items that the provider “knows or should know are not medically necessary.” In the other, CMS referred to a part of federal law stating that HHS may exclude providers from Medicare for submitting claims for excessive fees or unnecessary services, or for not furnishing necessary services.

In a recent OIG report, the office recommended CMS focus on physicians with the highest Medicare billings for improper payments. According to the OIG, 303 physicians received more than $3 million each in 2009. Ophthalmologists, along with radiation oncologists and internists, comprise the majority of the highest-billing doctors.

Meanwhile, the Obama administration announced it would consider releasing data showing the amounts individual doctors receive in Medicare payments each year in response to Freedom of Information Act requests.

Scheduled to go into effect March 18, the policy allows Medicare officials to “weigh the balance between the privacy interest of individual physicians and the public interest in disclosure of such information.”

Ophthalmology Hall of Fame inductees: Drs. Vladimir Filatov and Theo Seiler

Two new inductees to the Ophthalmology Hall of Fame will be formally announced at next month’s ASCRS meeting. They are the late Russian ophthalmologist Vladimir Filatov (1875-1956), who was the first in the world to perform corneal transplantation on a living patient with cadaver eyes, and Prof. Theo Seiler of the University of Zurich, a pioneer in laser refractive surgery.

Prof. Seiler was the first in the world to perform PRK in 1987 and is acknowledged as the inventor of corneal collagen crosslinking. He is credited with being the first to treat a human eye using an excimer laser. Dr. Seiler continues to lecture and has received numerous awards.

CMS schedules additional testing of ICD-10 codes

But physician advocates want a more robust format and wider participation.

After continued urging from such organizations as the American Medical Association, the Medical Group Management Association (MGMA) and the Workgroup for Electronic Data Interchange, CMS has scheduled “end-to-end” testing of submitted medical claims using the new ICD-10 codes due to be implemented in October.

The testing is scheduled for this summer. CMS has made few details available except to say that the testing, though limited in scope, would involve a “broad cross section” of different types of providers, claims and submitters.

The CMS action marks a major turnaround from its initial position to not test the ICD-10 codes before the October 1 start date. The first softening of the CMS position came when the federal agency scheduled a week of front-end testing from March 3 to 7. However, MGMA called the March front-end testing “insufficient” because it would only demonstrate whether a provider transmitted a claim and if the Medicare contractor on the other end received it. The testing did not determine whether a claim had been approved.

CMS has said little about who can participate in the new round of testing. MGMA has urged CMS to expand the scope of the testing so that any provider who wishes to may participate. MGMA also has requested that CMS quickly disseminate test results.

“This more robust testing is imperative to identify potential operational problems similar to what was experienced during the rollout of healthcare.gov,” said Susan Turney, MD, president and CEO of MGMA.

Ophthalmology losing hours in med schools

New survey shows a continuing decline in ophthalmic instruction.

By René Luthe, Senior Associate Editor

An alarming survey into the state of ophthalmic education in standard medical school curriculum has found the specialty continues to decline in its share of attention.¹ The survey of 135 member medical schools of the Association of University Professors of Ophthalmology (AUPO), plus 30 osteopathic and 40 non-AUPO-affiliated allopathic medical schools in the United States and Canada, conducted over 2012-2013, shows that ophthalmology lost ground both in required hours and in clinical rotations.

Specifically, the investigators reported that while preclinical ophthalmology education remains “nearly universal” among the 109 AUPO institutions that responded, in the form of lectures and basic examination skills during the first two years of medical school, clinical exposure to ophthalmology patients “was more variable.” Twenty-one percent of schools offered no additional ophthalmic teaching, 24% offered an additional one to two hours, 35% offered another three to seven hours and 20% offered another eight or more hours of ophthalmic instruction.

Only 18% of the AUPO respondents required a clinical rotation in ophthalmology. In surveys conducted in 2000 and 2004, 68% and 30% of members respectively required a clinical rotation in the specialty. All of the respondents offered an elective rotation in ophthalmology.

Evan Waxman, MD, PhD, of the department of ophthalmology at University of Pittsburgh School of Medicine, and senior study author, says the results point to a need for medical schools to do better of ophthalmic education.

“Patients with eye complaints present to their primary-care doctors because they have a reasonable expectation that their doctors will know something about their eyes,” he says. “Now we know the majority of physicians can graduate from medical school without adequate ophthalmology training.”

Dr. Waxman attributes the decline in ophthalmic education to the trend of academic ophthalmology departments separating from their medical schools over the last decade or so.

That means ophthalmology is less likely to recruit the best and brightest from medical schools. “But more importantly, when we separate from our medical schools our colleagues in primary care and other fields don’t know who we are and what we do,” he says. “They are less likely to understand the role of the ophthalmologist in the health of our patients.”

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Get involved in clinical trials

tip of the month

Participation in clinical trials is one area that some — especially smaller — ophthalmology practices tend to overlook. Here, Michael Korenfeld, MD, ACOS, of Comprehensive Eye Care Ltd. in Washington, Mo., explains why your practice and your patients can benefit from your involvement in clinical trials.

1. Participation in in studies identifies you as an alert, cutting-edge practice seeking to offer your patients the newest and best treatments.

2. When you choose patients from your practice to be in a trial, they gain the benefits of comprehensive monitoring, free medications and a per-visit stipend to offset the time and travel the study requires.

3. As far as finding studies that need investigators, start by contacting study sponsors. All FDA-approved studies are published at clinicaltrials.gov. so I recommend checking this site. Many sponsors will ask you to participate in subsequent studies if you and your staff do a good job on the first one; and you should do just that.

PhotoMedex to acquire LCA-Vision

PhotoMedex Inc., a company focusing on the dermatologic and aesthetic sector, and LCA-Vision, which was a pioneer in providing laser refractive surgery in multiple branded centers nationwide, have signed a definitive agreement in which PhotoMedex will acquire LCA-Vision for $5.37 per share in cash, or approximately $106.4 million. LCA-Vision has operated under the LasikPlus brand.

PhotoMedex is a global skin health company that provides integrated disease management and aesthetic solutions to dermatologists, professional aestheticians and consumers. The company said it believes owning the LasikPlus centers will give it a national footprint and also provide opportunities to introduce its laser skin care procedures for psoriasis and vitiligo into the LasikPlus centers.

Study challenges use of aspirating speculums

They may irritate dry eyes in cataract surgery.

By Bill Kekevian, Senior Associate Editor

Using an aspirating speculum for cataract procedures may aggravate dry eyes, according to research from South Korea.¹ The prospective study evaluated the short-term influence of aspirating speculums on dry eye following cataract surgery. The study, published in the journal Cornea, found elevated dry eye parameters during the early postoperative period.

The dry eye parameters the researchers, from Gachon University Gil Hospital in Incheon, measured included conjunctival staining, tear film break-up time, conjunctivochalasis grades and ocular surface disease index evaluated.

The researchers studied 58 eyes undergoing cataract surgery. Half were treated using an aspirating speculum and half were treated with a nonaspirating speculum. While the nonaspirating speculum group showed aggravation by tear film break-up time and conjunctivochalasis grades on day one postoperativly, the aspirating speculum group showed the same aggravation by tear film break-up time and conjunctivochalasis grades up to seven days postoperatively, the authors reported. The parameters for both groups returned to preoperative values one month after surgery.

Surgeons’ comment on study

David R. Hardten, MD, of Minnesota Eye Consultants, says trauma at the time of surgery can impact dry eye symptoms. Although this is a small study and only looks at one factor, he says, “there may be some intuitive basis of this study. The active air pulling across the conjunctiva may temporarily irritate the goblet cells or epithelium of the conjunctiva. There is still much to learn about factors involved in dry eye around the time of surgery.”

Dr. Hardten recommends ophthalmologists identify dry eye and meibomian gland dysfunction preoperatively.

However, Bradley Black, MD, of Dr. Black’s Eye Associates in Jeffersonville, Ind., does not think the study findings will have a wide impact. He points to several metrics the authors have not taken into account, including postoperative drop regimen, patient medications and environmental factors, among others.

More importantly, though, Dr. Black wonders if temporary corneal dryness isn’t a fair trade off for other benefits of aspirating speculums. “Although I do not use an aspirating speculum during cataract surgery, they offer some potential benefits such as visibility and removal of pooled fluid that could be a reservoir for bacteria from the lids or lashes, all of which might outweigh the temporary concern of corneal dryness,” he says. Dryness issues “could easily be handled by recommending artificial tears and/or aggressive ocular surface disease treatment preoperatively,” he adds.

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