August 06, 2012
3 min read

Surgeons find ways to deal with costs of noncovered tests for cataract surgery

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The ophthalmic surgeon is free to order any test he or she believes might be helpful in planning surgery for a preoperative cataract patient, but third-party payers, including Medicare and Medicaid, will not pay for them. The surgeon can charge for a complete eye examination if performed in advance of the day of surgery and for biometry.

In special situations, other tests may be justified and reimbursed. For example, if the slit lamp examination shows cornea guttata or if there is a history of ocular surgery or corneal trauma, specular microscopy will be covered. However, in the routine case, if the surgeon would like to screen for occult endothelial or macular pathology by ordering specular microscopy and a macular OCT, this is a noncovered service.

In the patient who is undergoing a lifestyle-enhancing premium IOL implant to correct astigmatism or astigmatism and presbyopia, it is simple to include these and other tests that enhance planning, such as corneal topography, in the package fee charged to the patient. These tests help justify the additional fee charged in refractive cataract surgery and enhance the quality of preoperative screening and patient counseling.

Most of us who do refractive cataract surgery include, at a minimum, OCT and topography in our premium IOL package. I also like to get specular microscopy, tear film osmolarity and wavefront aberrometry. Many of us find that these extra tests reveal pathology that was undetected on our routine eye examination. In many cases the detection of this pathology significantly influences our surgical plan and patient counseling. It does not take long before one begins to feel a little ill at ease proceeding to surgery in a standard case without the benefit that these additional tests provide.

One solution is to simply order these extra tests on all patients and absorb the costs. Many surgeons have chosen to accept this extra burden, but the continuing squeeze between increasing practice costs and reduced reimbursement makes this difficult for most.

A second approach is to look ever more carefully during our preoperative examination for symptoms and signs of ocular surface disease, corneal pathology and macular/retinal disease and then order those tests appropriate to the diagnosis. This is the approach chosen by most ophthalmologists, but those of us who do premium IOLs know that even with increased vigilance we miss important findings, including atypical topography, early keratoconus and subtle macular changes such as mild epiretinal membranes.

This has led a few practices to create a third premium channel and offer patients advanced preoperative diagnostic testing at the patient’s request for a fee. The patients are advised of the opportunity and potential benefits in the same fashion and at the same time they are offered astigmatism correction or astigmatism and presbyopia correction. We have recently adopted this approach in our practice. This offering requires thoughtful consideration and consultation with legal and reimbursement representatives before adoption, and full disclosure and transparency regarding the costs and potential benefits to patients are mandatory.

An Advanced Beneficiary Notice signed by the patient and housed in the chart is highly recommended. Increasing patient-shared responsibility for the costs of the highest quality care is becoming a fact of life in modern medical care delivery in the U.S. and, for that matter, around the world. This is another example of that trend.

I believe the only way the highest quality care can remain available in our country is through patient-shared responsibility for some of the costs. In the next decade, I expect Medicare to transition from the current defined benefit plan to a defined contribution plan, as it was for the first 20 years of its existence from 1965 to 1985.

The alternative, as I look to the future, is a dismal scenario of continuous reduction in quality of care and even denial of care, the death of innovation, and increasingly stressed and even bankrupt government as the senior population continues to grow.

For now, we offer our patients the best care we can inside the current rules and regulations. In some cases, we simply give away the care when a patient in need cannot afford what is indicated. In others, in order to afford the free care delivered compassionately to those in need, we charge those who can afford to pay extra for a premium outcome when they desire it. Far from a perfect system, but it is the nature of practice today.