July 01, 2006
4 min read

Reimbursement, presbyopia-correcting IOLs among hot topics in ASCs

In this report from the OSN Section Editor Summit, R. Bruce Wallace III, MD, gives an update on reimbursement issues, the role of presbyopia-correcting IOLs, anesthesia, and ownership and liability insurance in ASCs.

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A note from the editors:

Ocular Surgery News convened its annual Section Editor Summit in Las Vegas in March. In this fifth installment of reports from the OSN Section Editor Summit, ASCs Section Editor R. Bruce Wallace III, MD, gives an update on issues in ASCs.

Last year at this meeting, I said Medicare ASC rates were scheduled to be frozen until 2008. Well, unfortunately, they are not frozen. The Nd:YAG laser procedure rates for ASCs will decrease to the outpatient rates for hospitals in January 2007. We thought we were going to get a little bit of a break with this parity, but it’s going to go in the other direction, at least for that particular procedure. As a result, about one-third of our profits will be eliminated for YAG.

Studies are under way to justify some adjustments. Currently, ASCs get about 30% lower rates than hospitals for the same procedures. There is a bill in Congress, HR 4042, that calls for ASCs to be paid 75% of the hospital rate, which would be about a 5% increase. One of the things we are hoping to add into this bill is for more procedures to be covered in the ASC. This is not ready to be approved yet, so we’re just going to need to watch that.

There is a current moratorium on specialty hospitals that the hospital lobby was able to pass. We were concerned about ASCs being part of that target, but so far that hasn’t happened. There is more certificate-of-need legislation going on in various states, so this is more of a state-by-state issue.

There has been at least one report of economic credentialing of MDs, which essentially means, “How many operations are you doing for us today at the hospital in order for you to stay on staff?” Keep in mind that in order for someone to have an ASC position or ownership of an ASC, they need to have hospital privileges to have the ability to admit emergency patients. This could make it so they really couldn’t be investors in ASCs, so hospitals wouldn’t allow credentialing.

Presbyopia-correcting IOLs

R. Bruce Wallace III

The hot area right now in ophthalmology, and particularly in anterior segment surgery, is refractive lens surgery, which is something that I have been working on for a number of years. This is not a new idea, but it’s just come to the forefront over the past few months. This has been brought about by aging baby boomers. Refractive lens surgery is one procedure for life, and I think it is better for hyperopia than other procedures. It spares the central cornea, which may be a good thing. It also utilizes the equipment and facilities already available to us.

The CMS ruling in 2005 was quite a coup. We had the Advanced Medical Optics Array lens at $175; all of a sudden we now have these other lenses, such as the crystalens (eyeonics), ReSTOR (Alcon) and ReZoom (AMO), around $900, and that may increase. Some people think that this could be a problem, but I think it’s actually a major win for us that we can start billing these patients because we’ve been giving this away, and even I have been doing it for years. I have even been giving limbal relaxing incisions away, but it’s worth a whole lot more than Medicare is paying for what patients are getting for these procedures. In the general marketplace these procedures are costing somewhere around $3,800 and $5,000 an eye. Much less than that is being spent by the government to reduce a person’s dependence on bifocal glasses. I think this is a step in the right direction, and it has gained a lot of attention.

Of course, as we know, there is a separate charge for the facility. That’s where the ASC comes in. But now the surgeon can also charge for the services that they are providing that aren’t considered part of the cataract procedure but rather a refractive service. You need to be careful and document that you are actually charging the proper amount for that, but it is considered the refractive component.

I had a patient we operated on not too long ago, and Medicaid paid for the extra procedure. You cannot tell a good candidate just by looking at someone in a chair. Over the next few months, I think we’re going to see this become better understood — how surgeons present this to their patients in a proper way, the right forms needed. This kind of caught us by surprise, and we’re all trying to learn together how to do this properly.

Fewer anesthetists

There is a reduction in the number of people who are willing to perform anesthesia in ASCs, and that’s a problem. It gets to be sort of mundane for a lot of anesthetists and anesthesiologists, and there is not a lot of reimbursement out there unless they can be efficient.

MD hospital admitting privileges are required. There are some times when the person administering the anesthesia is not on the panel of the facility or the surgeon’s insurance company, and that can be a problem. We just had that happen recently, where a patient almost went elsewhere because the anesthesia was not covered. So we had to work something out with them. This may become more of an issue over time.

ASCs Section Editor R. Bruce Wallace III, MD (right) and Alan E. Reider, JD, (left) at the OSN annual Section Editor Summit in Las Vegas in March. Dr. Wallace spoke about issues affecting ASC owners and other surgeons.

ASC ownership

As far as ownership, this is probably a good time to get in before there is a moratorium on ASC building. I think a lot of surgeons have lost a lot of revenue because they stayed in hospitals when they had a 10-year window of making quite a bit more in a surgery center and having even better services because they can choose the staff they want. They can choose the equipment they want and probably be more efficient.

As far as professional liability insurance, OMIG has some definite requirements. If there is anything beyond what OMIG would allow, that has to be cleared with OMIG. There is other insurance besides OMIG, but that’s the most common one for ophthalmology.

And, of course, there are increased costs now. We’re not really getting what we deserve on the professional side, but also on the facility side we’re not getting the necessary increases compared with what we’re required to spend on certain types of equipment or disposables. We are looking at per-case cost going up and reimbursement not necessarily going up.

For more information:
  • R. Bruce Wallace III, MD, can be reached at 4110 Parliament Drive, Alexandria, LA 71303; 318-448-4488; fax: 318-448-9731; e-mail: rbw123@aol.com.