TAKEAWAY POINTS
🔹 Critical but Low-Volume Care
Corneal tissue procedures are low in volume compared to cataract surgeries but are often sight-saving and essential for patient outcomes.
🔹 Reimbursement Gaps Impact Access
Medicare Advantage and private insurers frequently under-reimburse corneal tissue, placing financial strain on ASCs and eye banks and potentially delaying care for patients.
🔹 Contract Awareness is Crucial
ASCs must review insurance contracts carefully—ideally with support from eye banks or reimbursement consultants—to secure proper payment and sustain access to corneal transplant care.
The number of corneal tissue procedures performed by surgeons at your ASC likely ranks low compared with, for instance, cataract surgeries. Member eye banks of the Eye Bank Association of America (EBAA) supplied roughly 51,000 corneas for transplant within the United States in 2023. That compares with the millions of cataract surgeries performed in the US each year—roughly 3.7 million, according to one estimate.1
Yet, those corneal procedures are often sight-saving procedures. They may be low volume, but they are high impact. Unfortunately, obtaining full reimbursement for corneal tissue can present a thorny problem for ASCs. “It is an ongoing issue for surgeons as well as facilities,” says Christina Psalms, business development director at CorneaGen. Kevin Corcoran, CAE, president and CEO of the EBAA, concurs. “This has been an issue for eye banks for many years,” he says.
In this article, we’ll discuss the impacts this lack of reimbursement can have on ASCs, surgeons and patients, and provide potential solutions. But first, let’s clarify the problem.
Not a Pass-Through
If a patient at your ASC who needs corneal tissue is using traditional Medicare, the fee for corneal tissue will be processed as a pass-through and will be reimbursed at full fee, notes Mr. Corcoran. The problem arises when the patient has Medicare Advantage or private insurance. ASCs may sign an agreement that doesn’t provide full reimbursement for corneal tissue, Mr. Corcoran explains. “The problem for eye banks is that we’re not parties to that contract. We’re not involved in those negotiations.”
The ASC may sign an agreement that reimburses the ASC a fixed amount or percentage of the invoice. The ASC may then turn to the eye bank and ask for a discount on the corneal tissue fee.
With more patients using Medicare Advantage, stakes are getting higher. “It is a major issue, particularly since about two-thirds of all cornea transplants are performed on people who are over age 65,” says Mr. Corcoran. This dynamic leaves eye banks with 2 challenges, he suggests. First, both legally and morally, eye banks can’t mark up corneal tissue. They simply are reimbursed their direct cost for recovering, preparing and providing the tissue, as well as some cost to maintain the operations of the eye bank.
Second, with few exceptions, eye banks are sole-purpose entities, meaning all they do is provide corneal tissue for transplant. They can’t turn a profit on some other line of business. So, if an eye bank agrees to provide a discount on corneal tissue, “that's coming right off their bottom line, and they don't have easy ways to make up for that,” says Mr. Corcoran.
What’s more, with interventions such as Descemet membrane endothelial keratoplasty and Descemet’s stripping endothelial keratoplasty, a surgeon may be operating on a patient who is under age 65, thus getting more into the realm of private insurance, notes Bernie Iliakis, president and CEO, CorneaGen.
Further, Medicaid too may not reimburse for corneal tissue at full fee. In Georgia, for instance, Medicaid will reimburse a surgeon and an ASC for corneal transplant procedures, but will deny reimbursement for the corneal tissue, according to Eric Meinecke, CEBT, president and CEO, Georgia Eye Bank. In many states, notes Mr. Meinecke, Medicaid will not follow what Medicare does.
Important Impacts
For the ASC, this failure in reimbursement can have various consequences. The ASC can take a loss on the fee; the eye bank can take a loss; or the ASC can decide to perform fewer corneal tissue procedures, according to Mr. Iliakis. None of those options, he says, are ideal situations.
“It’s a pretty frequent occurrence that a surgery center will reach out and express difficulty with a particular carrier,” says Mr. Meinecke. “Often, they request us to reduce the invoice or provide a tissue for no reimbursement. This is due to reimbursement challenges with their patient’s carrier, and they’re not getting the approvals.”
Another consequence: The procedure moves from the ASC to a hospital. “Increasingly, we’re seeing ambulatory surgery centers in particular refusing to take cornea transplants, or taking a lot fewer of them and pushing them into the hospital setting,” says Mr. Corcoran.
To be sure, a surgeon will likely want to do the surgery at the ASC. “They would much prefer to stay in their ASC because that’s the environment that they are familiar with,” according to Mr. Meinecke.
As Mr. Corcoran puts it, “You have a home field advantage if you’re in an ophthalmic ASC, and you’re playing on the road, in many cases, if you’re in the hospital.”
Perhaps most regrettable is that this failure to fully reimburse for corneal tissue can cause needless suffering for patients. “It definitely has an impact on patient care and outcomes, because you’ve got folks who are visually impaired or blind who need to get their sight back, need their vision back, and that's being delayed needlessly, just because of the reimbursement policies of the Medicare Advantage plan,” says Mr. Corcoran. (For more on reimbursement complications and the patient, see the sidebar.)
Care With Contracts
To address this issue, ASCs should exercise care when they enter into agreements with Medicare Advantage plans or private insurance carriers. “It comes down to understanding what’s in the contract,” says Mr. Corcoran. That may be easier said than done, because these agreements are often detailed and complex. Understandably, the ASC may pay great attention to high-volume procedure such as cataracts but be less diligent when it comes to low-volume corneal tissue procedures.
That’s where an ASC can get expertise from an eye bank. The EBAA eye banks, according to Mr. Corcoran, encourage their surgeons and surgery centers to contact them before signing a contract with an insurer. Georgia Eye Bank, for instance, has retained a consultant that will help an ASC free of charge. Similarly, CorneaGen will provide a reimbursement consultant, NMD Healthcare Consulting, free of charge to review insurance contracts.
Honoring Wishes
“We really feel strongly that a patient shouldn’t go without a cornea transplant, if that’s what they need, based on financial issues,” says Mr. Meinecke. “Our mission is to honor the wishes of donors and families and to provide the gift of sight.” OASC
Patient Counseling
So, what do surgeon-owners of ASCs need to tell the patient about the potential lack of insurance coverage for corneal tissue? Fortunately, that may be the easiest part of the corneal-tissue reimbursement conundrum.“In the vast majority of patient encounters, the surgeon would likely have no or very limited knowledge on whether the reimbursement for the corneal tissue will be an issue or not during the patient consult so, this would be an unlikely scenario,” says Bernie Iliakis, president and chief executive officer, CorneaGen.
The coverage and payment for the tissue is generally the responsibility of the surgeon’s staff, who will contact the respective payor to obtain a prior authorization (if it’s a commercial payor) which they may inform the surgeon prior to the patient engagement on whether coverage has been authorized by the payer. As detailed in the article, the ASC or the eye bank may choose to accept the loss on the fee for corneal tissue. So, while the lack of reimbursement may delay the patient’s treatment via referral, etc, there would likely be no need to discuss the issue with the patient.
Reference
1. Rossi T, Romano MR, Iannetta D, Romano V, Gualdi L, D'Agostino I, Ripandelli G. Cataract surgery practice patterns worldwide: a survey. BMJ Open Ophthalmol. 2021 Jan 13;6(1):e000464. doi: 10.1136/bmjophth-2020-000464. PMID: 33501377; PMCID: PMC7812090.