Navigating complex and ever-changing insurance rules to pursue fair reimbursement requires a significant commitment of time and effort for ophthalmology practices. To succeed, they must not only transform time savings into cost efficiencies, but carefully track every dollar that passes through their doors as well.

In this article — the final installment in a two-part series about how practices can maximize reimbursement (for part one, see bit.ly/3rdAzln ) — we’ll consider strategies for tracking and recouping dollars spent. But first, it’s crucial to understand why reimbursement has become so challenging.

IDENTIFYING CHALLENGES

As mentioned in part one, an 8.5% cut to Medicare reimbursements¹ in 2023 has led to reduced payments for initial cataract surgeries, denials for second-eye cataract surgeries and shrinking reimbursements for corneal donor tissue.

To complicate matters, insurance companies often do not reimburse enough to cover the cost of a drug. A case in point is a photosensitive vitamin B2 solution that has transformed keratoconus treatment. Until its developer merged with another company,² the $3,500 drug was reimbursed at different rates by various insurers, in some cases at just one-third of its cost.

Insurers may also restrict reimbursement by dictating that certain surgeries be performed in ASCs, which tend to have lower fee structures than hospital-based outpatient departments.

At Duke Eye Center, I collaborate with Health Center Administrator Amanda Mestler, COT, to respond to these challenges by coding accurately, tracking treatments and their associated reimbursements, and pushing back at insurers and vendors when appropriate payment isn’t provided. Ms. Mestler has worked extensively across all aspects of ophthalmology for 20 years and is well equipped to handle these challenges due to her skills in ophthalmology leadership, clinical operations oversight, template management and financial reporting, as well as her passion in the promotion of accountability and clinical efficiency.

Our process involves:

• Creating daily reports that track the medications and procedures administered within the previous 6 months, so that we can check whether we’re covering our expenses, recognize slow payment trends for specific treatments and appeal denials.
• Tracking high-dollar medications and procedures via a shared spreadsheet so that we understand insurers’ reimbursement and denial patterns. This helps us keep doctors informed and drugs in stock.
• Engaging the team by asking staff members to escalate current or anticipated reimbursement problems for discussion.

The result: doctors know when they’re not being reimbursed for certain services, which helps them shape their practice patterns.

“Unfortunately,” Ms. Mestler says, “we sometimes have to let doctors know that insurers are denying a certain treatment.”

CODING CORRECTLY

When it comes to avoiding denials, there’s nothing more important than accurate coding.

Practices need to chart ICD codes that accurately reflect patients’ conditions and CPT codes that correctly identify the treatments received.

Some treatments are particularly tricky to code, such as a medication for geographic atrophy that has very strict eligibility standards and won’t be reimbursed by insurers unless doctors note the size of choroidal neovascularization lesions in charts.³

Common billing mistakes include:

• Not charging for a patient’s second eye after a bilateral procedure
• Not billing for every unit of medication used
• Neglecting to invoice for both the injection and the drug after administering intravitreal treatments
• Accidentally zeroing out the charges for a medicine.

To avoid these glitches, clinic administrators should give doctors and staff access to the full, current range of codes by continually updating their EMRs. Also, they should regularly check the work of outsourced coders.

“You’ve got to stay on top of coding every month to make sure charges are going out the door correctly,” says Ms. Mestler. “After billing, you need to check how much you were reimbursed and why it may not be enough to cover your costs. That way, you’ll have a fighting chance of getting back the amount your practice deserves.”

Coding issues may also influence which services practices offer. Unlike drugs with temporary C codes, those with permanent J codes are eligible for reimbursement across most insurance settings.⁴ That’s why it’s financially prudent for practices to gravitate toward those products — and, for the same reason, toward procedures with assigned CPT or HCPCS codes.

A good example is a product we recently introduced at Duke Eye Center — a 0.4 mg dexamethasone ophthalmic insert for the treatment of ocular inflammation and pain after surgery. We’ve had an excellent experience with reimbursement for this treatment, both in the surgical suite and the office, because of its dedicated J code.⁵

PUSHING BACK

When prior authorization is denied, practices can appeal to insurance companies. But, before taking this formal step, the treating physician can initiate a conversation with a doctor on the insurer’s staff.

“Sometimes peer-to-peer communication clarifies an issue much more successfully than words on paper,” Ms. Mestler says. “Practices need to teach their staffers when to push for this.”

If billing for a specific procedure or medication brings repeated denials or low reimbursement that doesn’t cover its cost, practices may also push back at the vendors that sell these treatments. While vendors may try to blame denials on practices, clinic managers can demonstrate that they are billing properly and may need to stop using the product if payment problems aren’t rectified.

When additional help is needed, practices can turn to the ASCRS (ascrs.org ) and AAO (aao.org ). Recently, in collaboration with AAO, ASCRS spoke out on behalf of ophthalmologists by fighting to overturn Aetna’s rule against same-day authorizations for cataract surgery — a policy that led to many delays of this safe and medically necessary procedure. The rule was abolished in all but a couple of states.⁶

INVESTING WISELY

With so many challenges to reimbursement, when does it make sense for practices to invest in new technologies? This proposition requires a careful set of calculations, as upgrading first-generation LASIK equipment, for example, could cost half a million dollars.

“We have to figure out how many patients we think we’re going to treat, the cost of each procedure, whether the treatment has a permanent reimbursement code, and our anticipated costs for laser gases, warranties and maintenance agreements,” Ms. Mestler says. “The other question is: Do we trust everything the company is telling us about the device and that it really does perform?”

Ultimately, clinic managers must consider how much value a device really adds: Does it introduce a new technology or simply update a service the practice already provides?

EMBRACING TRAINING

While Duke Eye Center is large, with more than a dozen locations, many smaller, standalone practices have less experience negotiating contracts.

To help provide them with the right tools, Ms. Mestler and I lecture at AAO and ASCRS meetings; in fact, we’ll be discussing our reimbursement strategies in a podcast with AAO this fall in a talk titled “Learned Lessons From Implementing Change” (bit.ly/45XyRUk ).

In addition, we often send our technicians to these industry meetings to train their peers, and administrators from other practices frequently reach out to us to learn about our reimbursement strategies.

TAKING A TEAM APPROACH

Within an ophthalmology practice, front-desk administrators usually handle financials while clerks on the backend work with technicians. But, to realize optimal payment for services, everyone on the team must understand reimbursement strategies, from proper coding to pushing back after receiving denials. Most important is that staff members tell doctors which medications and procedures are being regularly denied for reimbursement.

“You have to have direct communication and trust in each other,” Ms. Mestler said. “It’s helpful to have financial data to take to doctors so you can show them they’re not getting paid, rather than just telling them. I think that’s key.” OM

REFERENCES

1. Gallagher J. Ophthalmologists Face 8.5% Cut in Medicare Reimbursement for 2023. Glaucoma Physician. Published December 1, 2022. https://www.glaucomaphysician.net/issues/2022/december-2022/web-exclusive-ophthalmologists-face-8-5-cut-in-med . Accessed July 21, 2023.
2. Glaukos. Glaukos and Avedro Announce Definitive Acquisition Agreement. Investors.glaukos.com. Published Aug. 7, 2019. https://tinyurl.com/2p9kn3s8 .
3. Apellis. Syfovre Billing and Coding Guide. Effective July 1, 2023. https://syfovreecp.com/wordpress/wp-content/themes/apellis/pdf/billing_and_coding_guide.pdf . Accessed Sept. 6, 2023.
4. Torrey T. What are CPT Codes? Verywell Health. Updated July 9, 2023. https://www.verywellhealth.com/what-are-cpt-codes-2614950 . Accessed Sept. 6, 2023.
5. Corcoran S. Ophthalmology Management. New therapy = new code. https://www.ophthalmologymanagement.com/issues/2019/september-2019/coding-amp;-reimbursement . Accessed Oct. 10, 2023.
6. ASCRS. Aetna Drops Prior Authorization Requirement for Cataract Surgery. ASCRS.org . Published June 30, 2022. https://ascrs.org/news/ascrs-news/aetna-drops-prior-authorization-requirement . Accessed Sept. 6, 2023.

HEIDI CAMPBELL, COT, is the director of clinical operations for Duke Eye Center at Duke University Health System. She has a passion for mentoring and training technicians to transition into leadership roles from clinic manager to administrator. She was responsible for effective changes in clinic flow across all of the Duke Eye Center locations, including its main campus and all satellite clinics, resulting in a 30% increase in arrived visit volume in a two-year time frame with increased patient and employee satisfaction scores.