Tackling tissue reimbursement

Cornea transplant reimbursements have eluded some surgeons.

By Robert Stoneback, associate editor

A little more than 50,000 corneal transplants are performed annually in the United States, and some ophthalmologists have struggled to receive reimbursements for the procedure.

Proper reimbursement “is a concern because it can limit patient access to receiving corneal transplantation,” says Monty Montoya, president and CEO of CorneaGen, a company that provides corneal transplant tissues to countries around the world.

One of the main challenges with reimbursement, says Mr. Montoya, is that corneal tissue is a pass-through reimbursement under Medicare, but is not treated that way by private insurance; even as a Medicare pass-through, though, Medicare only covers about 65% to 70% of the procedure.

Additionally, with private payers, the reimbursement is being lowered due to transplantation costs being bundled with other procedures. For example, Mr. Montoya says, a facility may be reimbursed by insurance $5,000 for an entire corneal transplant procedure, but the tissue alone costs $4,500. That leaves only $500 to pay the facility, surgeon and other staff, which typically means the clinic loses money.

A MATTER OF PERSPECTIVE

Compounding the issues with reimbursement, corneal transplants are often a small portion of the activity in ASC or hospital-based outpatient facilities, sometimes only making up a few hours per month, says Mr. Montoya. This means staff are not as familiar with the related billing processes and often don’t file them correctly, he says.

This is why CorneaGen is currently providing two kinds of reimbursement support, continues Mr. Montoya. First, the company wants to help facilities renegotiate contracts with private payers so they can be more appropriately reimbursed for corneal transplants; second, CorneaGen helps facilities train their accounting personnel to appropriately file reimbursement claims.

One of the biggest hurdles is changing the perception private payers have about corneal transplants, says Mr. Montoya. Part of that is scale — in the United States, a little more than 50,000 such transplants are performed each year. For comparison, Mr. Montoya says the number of U.S. cataract surgeries performed each year is around 4 million.

“Corneal transplants are such a small piece of the pie that it doesn’t get the same focus as these larger volume procedures,” says Jared Young, CorneaGen vice president of marketing and communications. “So, having a company like CorneaGen that can raise the profile of corneal transplants and makes it more prominent,” can give increased visibility of the procedure to these private insurers.”

The cost burden to insurers is much greater if the insurers don’t pay for cornea transplant procedures, says Mr. Montoya. A transplant procedure can cost $15,000, but this is much less than the long-term costs of corneal blindness, which can result without the procedure. Those related health-care issues can cost $50,000 to $60,000 over five years, he says.

PROVIDING ADVOCACY

Audrey R. Talley Rostov, MD, owner of Seattle, Wash.-based Northwest Eye Surgeon, found CorneaGen’s advocacy extremely helpful a few years ago.

At that time, Washington’s Medicaid agency would not approve tissue reimbursement for DSEK or DMEK. They would have rather surgeons do a more invasive penetrating keratoplasty (PK) procedure than DMEK, she says, because the full-thickness grafts used in PK were cheaper than DMEK’s partial-thickness grafts.

Thankfully, continues Dr. Rostov, CorneaGen shared data with her state’s Medicaid program. The data showed that while the tissue cost was greater for DMEK and DSEK it resulted in lowered overall costs due to decreased follow-ups, recovery and time away from work. Washington insurers have now started covering grafts and procedures for DMEK and DSEK, Dr. Rostov says. OM