GLAUCOMA IN THE ASC
PART 3 IN A SERIES

Vigilance Goes a Long Way

How we apply it to keep procedures profitable

By PATTI BARKEY, CEO, COE

Part of our mission at Eye Surgery Center of North Florida is to provide the safest, most effective, and up-to-date treatments for all patients who need our care. Ever-changing insurance coverage and reimbursement policies haven’t made that easy in the glaucoma segment. Because we want to continue to serve those who require sight-saving IOP-lowering procedures in the ideal environment of the ASC, we’ve intensified our efforts to ensure these glaucoma procedures are economically viable.

Here are some strategies that work for us.

Re-assess Your Procedure Mix

Prior to the latest round of reimbursement reductions, our surgeons stopped performing trabeculectomies, because they found them to be very time-consuming — both in the clinic and in repeat trips to the ASC. With new types of IOP-lowering procedures becoming available, we have other options. Many of the newer options, designed for earlier intervention, may help some patients avoid trabeculectomy all together. Currently, the glaucoma procedures performed in our ASC are Ahmed tube shunt procedures and associated graft and shunt revisions, selective laser trabeculoplasty (SLT), and iStent (Glaukos) with cataract surgery.

Negotiate

Whenever possible, we negotiate — and re-negotiate —insurance carrier contracts for more favorable reimbursements. In our area, however, negotiating volume discounts with suppliers is often a better approach. For example, now that patch graft material is no longer separately reimbursed when used in tube shunt, graft revision, or shunt revision procedures, buying graft by the piece is cost-prohibitive. Our surgeons don’t consider creating scleral tunnels to be a good alternative, so we use the Tutoplast sclera patch graft (IOP Ophthalmics), which is available in multiple sizes, has a long shelf life, and can be stored at room temperature. We arranged with the supplier to pay a lower price as long as we purchase 35 or more grafts at a time. We spend more up front, but we can retain more profitability per case. Similarly, we now purchase 10 Ahmed shunts (New World Medical) at a time to receive a better price than we would buying them individually. Some vendors don’t require us to buy our entire discounted volume all at once as long as we commit to a certain number or amount of product per year. For us, obtaining a volume discount is the only way to go with all of our glaucoma surgical devices and supplies.

Have a Cost-conscious Mindset

Only surgeons from our practice, Bowden Eye & Associates, utilize our ASC. This gives us more control over costs than other facilities that must accommodate the preferences of many more surgeons who may or may not consistently use the center. It’s also helpful, though, that we’ve made cost-consciousness part of our culture. Every surgeon and staff member works with that mindset. We all pay attention to important aspects of the business, such as inventory levels and changes in supply costs. We also live by the adage “never open a peel pack until you actually need what’s inside.” This allows us to avoid wasting an entire back table of supplies if they’re opened prior to the surgeon realizing he, for whatever reason, can’t proceed with the intended procedure. In addition, our surgery center operations manager is tasked with approving every order — watching for waste and auditing to ensure items used are billed, so we don’t erase our volume discounts.

Follow the Money

We don’t process any payment we receive without a detailed examination of the Explanation of Benefits (EOB) for the case. We pre-certify every case to verify what the insurance carrier will pay, and then we compare the numbers on each EOB with the other numbers we knew up front: the allowable charge based on our carrier contract; the amount we billed; the patient’s copay (collected prior to the day of the procedure); and our cost of supplies (based on invoice amounts divided by what is used per case). (See “Following the Dollars.”)

By staying aware of the numbers throughout the process, and doing this comparison every time, we know a case won’t be a financial loss ahead of time, and we ensure our payment is what we think it is supposed to be. If not, we challenge it, even if the discrepancy is as little as $5. Every detail matters, and errors are frequent. Sometimes the carrier doesn’t pay what it said it would pay. In other cases, either the cataract portion or the iStent portion of a combined procedure, but not both, are paid.

There’s less consistency than one might expect on the carriers’ end, so no claim is immune to errors. In some instances, we’ve asked patients to help us receive proper payment by asking them to call the insurance company in addition to our claim resubmission efforts. They’re happy to do it.

Consider Renting Equipment

We’re using state-of-the-art technology in the ASC, including a femtosecond laser, and because we’re a newer facility, we are still paying for some of that equipment. Therefore, we didn’t find it necessary to also buy our SLT laser. Instead, we rent one for half a day once per month. This gives us access to the equipment we need without the maintenance and warranty fees and other headaches that sometimes come with ownership. We may purchase an SLT laser in the future, but right now it’s not necessary for us.

Keep OR Staffing Lean

Most ASCs already do this, but there may be room for improvement. We function safely and efficiently with the surgeon, a circulator, a scrub tech, and the anesthesiologist in the OR, along with a pre-op nurse and a post-op nurse. (Standard of care in our area is conscious sedation via IV for all patients.)

Instrument Consistency and Care

We worked with our surgeons to standardize what is on the instrument tray for each glaucoma procedure, and it is everyone’s goal to ensure the lineup is adhered to in every case. We make reusable instruments last a long time by handling them with care. “Treat them like they’re yours” is another of our adages. Staff members are educated to always thoroughly clean and dry the instruments. Also, the surgeon hands instruments back to the scrub tech, rather than tossing them back onto the tray, which is a great way to keep them from bending.

Move the Case (if necessary)

This doesn’t happen too often, and we consider it a last resort, but we don’t hesitate to schedule a case at the hospital if we see that performing it in the ASC will come with a financial loss.

Get Back to Basics

If this sounds like a back-to-basics approach, that’s because common sense and vigilance go a long way in this situation. These strategies work well for our ASC, and they just might help you ensure glaucoma procedures are profitable in your ASC. ■

Patti Barkey, COE, is CEO/Administrator with Bowden Eye & Associates and Eye Surgery Center of North Florida in Jacksonville.