In an ideal world, ophthalmologists would be free to administer the medications and procedures they deemed most beneficial for their patients — in every case, without delay.

But in reality, staying financially solvent means making treatment decisions within a complex and ever-changing framework of reimbursement requirements. Most ophthalmologists have experienced the frustration of losing money on services, delaying procedures to await reimbursement decisions or being directed to use an alternative to their treatment of choice.

Practice administrators can’t change the policies set by the Centers for Medicare & Medicaid Services (CMS) or private payers, but we can craft strategies designed to maximize reimbursement. At the same time, we want those strategies to lift the burden of compliance off the shoulders of our doctors, allowing them to navigate the clinic with as little interference as possible.

In our large academic ophthalmology practice, reimbursement strategies fall into two general categories: measures that save time and those that save money. Both are critical, as ophthalmology practices can expect to sustain an 8.5% cut to Medicare reimbursements in 2023¹ — even as they struggle with inflation and shortages of both technicians² and doctors.³

Duke Eye Center has fortunately remained strong during the ophthalmologist shortage by making our eye center uniquely valuable to patients. We have gathered a robust and expansive group of hard-to-find specialists — including pediatric, oculofacial, neuro and oncology ophthalmology — into a practice focused on patient care.

Not every facility can carve out such a specific niche, but all can navigate a challenging economic environment by distributing resources effectively and streamlining work standards. Through collaboration with Amanda Mestler, COT, a health center administrator at Duke Eye Center, we have identified ways for ophthalmology groups to improve their practice patterns, billing-coding expertise and deployment of personnel.

In this article, the first of two, we will focus on ways to turn time into dollars in the clinic.

SAME-DAY AUTHORIZATIONS

Many private insurers — including those that are part of the Medicare Advantage program — require prior authorization for certain procedures, and overlooking that rule can result in denials. Essential to successful reimbursement is securing authorizations from payers before administering medications and procedures — as quickly as possible.

“First, practices need to ensure that a particular treatment is covered for a patient and if it requires pre-authorization,” Ms. Mestler says. “When prior authorizations are needed, practices should secure them the day treatment is ordered whenever they can. This prevents the need to bring patients back another day, filling slots that could have gone to others.”

Of course, some circumstances preclude same-day prior authorizations:

• Emergent procedures, in which time is of the essence;
• Medicare billing, which doesn’t offer a mechanism for prior authorizations; and
• Insurance company requests to review patient records, which can cause delays.

In some cases, though, there’s an argument for spreading services out across appointments. This can occur when payers reimburse certain services, if performed together, as a single, bundled payment. It’s good for practices to understand that reimbursement may be higher if these services are provided separately, whenever possible within patients’ treatment plans. For instance, it may be more cost-effective to conduct optical coherence tomography and visual field tests 3 to 6 months apart, rather than on the same day.

To keep the practice running smoothly, staff members should be trained to monitor authorization status and communicate approvals or denials to clinicians in real time.

At Duke Eye Center, ensuring that authorizations are completed prior to procedures is everyone’s responsibility. Doctors are very visual, so we have created a system of color-coded dots that we place on a tracing form that follows patients during their visits (Figure). The system allows clinicians to see at a glance if a patient is approved for several medications, one treatment or none at all — which, in turn, signals the need to consult a financial counselor or insurer.

Despite a recent push in our field to go paper-free, we find that this system saves time for our doctors. In addition, it allows them to remain focused on patients during appointments.

TREATMENT TIMING

Securing prior authorizations is a complex process that can sometimes lead to therapeutic delays and reduced reimbursements. Those delays and payment reductions can arise when insurers mandate step therapy, refusing to cover a specific medication until lower-cost alternatives have been used. This process has become common in the treatment of some retinal diseases,^4,5 with insurers calling for the use of biosimilars before name-brand drugs are introduced.

To balance out this cumbersome process, practices can look to medications that are not only reliably reimbursable but have the potential to save hours in the clinic. We found one such solution in dexamethasone ophthalmic insert,⁶ a resorbable, preservative-free intracanalicular steroid delivery system that provides up to 30 days of sustained-release treatment for inflammation and pain following ophthalmic surgery and ocular itching associated with allergic conjunctivitis. By eliminating the need for post-surgical steroid drops, we spare our clinical staff the responsibilities of calling in prescriptions and teaching patients to apply and taper down their regimens. This saves many hours, far outweighing the time it takes to administer the dexamethasone ophthalmic insert at the conclusion of cataract surgery, even for surgeons who conduct 20 to 30 procedures a day.

Fortunately, we’ve found that the insert is reimbursable in our hospital, outpatient departments and ASCs. Now, we’re exploring its use in our office settings.

CROSS-TRAINING

What can ophthalmology practices do within their own organizational structures to help boost reimbursement?

Cross-training technicians to support every specialty within a practice can make a big difference by eliminating the waiting around that can occur when these staff members need to hand patients off to each other. This not only streamlines our clinic schedule, but it also allows technicians to fill in for each other in case of absences.

At Duke, technicians are trained to conduct workups across every specialty, reviewing charts and running diagnostic tests for patients with glaucoma, corneal conditions or retinal diseases and for those visiting our oculofacial, pediatric or neuro ophthalmologists.

“When we first cross-trained our technicians, we were shocked to see how quickly they were able to move through appointments,” Ms. Mestler says. “As a result, our doctors were able to increase their templates while decreasing their cycle time. Ultimately, that made it possible for us to expand our patient base, thus increasing our profitability.”

Any practice can achieve a similar outcome by providing supervised competency training for technicians across a host of skills both after hours and during appointments with patients. Although this takes time and can temporarily strain the capabilities of a short-staffed clinic, it is beneficial in the long run.

TELEHEALTH

It might seem counterintuitive to recommend telehealth,⁷ or virtual appointments, a strategy that is reimbursed poorly, if at all.

While telehealth doesn’t allow for close examination of the eye, it allows practices to check in with patients before or after visits, providing value by shaving time from clinical schedules.

Our technicians use telehealth for time-consuming new-patient in-take in advance of complex appointments with ophthalmic genetics, ocular oncology or neuro-ophthalmology, communicating in video calls through our EMR system. This shortens appointment times so our doctors can treat more individuals in a day.

“The bottom line: Telehealth can be helpful in ophthalmology when convenience and time are more important than reimbursement,” Ms. Mestler says.

LOOKING AHEAD

Saving time is only one aspect of the quest for reimbursement. To survive, ophthalmology practices must also watch every dollar that flows in and out of their doors.

The second installment of this article will address the importance of coding accurately, carefully tracking practice patterns and reimbursements, and pushing back at insurers and vendors when appropriate payment isn’t provided.

Given the complexities of health insurance policies — complicated by staffing shortages and CMS reimbursement cuts — ophthalmology practices face significant challenges when it comes to securing fair payment for their services. Still, with the right strategies, we can successfully pursue our mission to improve sight and health of the patients we serve. OM

REFERENCES

1. Gallagher J. Ophthalmologists Face 8.5% Cut in Medicare reimbursement for 2023. Glaucoma Physician. Published December 1, 2022. Accessed July 21, 2023. https://bit.ly/3s0uqZO .
2. Williams RD. Coping With staffing shortages. American Academy of Ophthalmology. Published December 2021. Accessed July 21, 2023. https://www.aao.org/eyenet/article/coping-with-staffing-shortages .
3. Terveen, DC. Ophthalmology numbers cause for concern. American Academy of Ophthalmology. Published August 19, 2022. Accessed July 21, 2023. https://bit.ly/3OHKl7Z .
4. Goodman J, Shah AR, Woodke J. Retina — Biosimilars, dual inhibitors, and coding for new drugs. American Academy of Ophthalmology. Published May 2023. Accessed July 21, 2023. https://tinyurl.com/nhh7prvu .
5. Mott M. Step therapy: Clinicians’ concerns and challenges. American Academy of Ophthalmology. Published April 2022. Accessed July 21, 2023. https://www.aao.org/eyenet/article/step-therapy-clinicians-concerns-and-challenges?april-2022 .
6. CBS Colorado. Going dropless after cataract surgery thrills patients. CBSNews.com. Published August 26, 2020. Accessed July 21, 2023. https://bit.ly/43VkcXK .
7. Glasser, David B. Is there a future for telehealth in ophthalmology? JAMA Ophthalmol. 2023;141:61-62. https://jamanetwork.com/journals/jamaophthal mology/article-abstract/2799234 .

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 administrators. 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.