Ophthalmologists and eye center leaders discuss upcoming trends in the field.
Q: What are some of the challenges that ophthalmology centers face in the coming year?
Mark L. Gonzalez, MD, The Eye Center at MedStar, Washington (D.C.) Hospital Center: First, as in years past, the decreasing reimbursement has been and will continue to be a problem. With high overhead costs, many centers run on a relatively tight per case margin. Any decrease in this margin, when multiplied over the entire years' case load, may result in a significant fiscal stress and can shift the financial outcome of a center.
Q: In addition to reimbursement trends, claim denials are a big concern for eye centers. What effect do they have on your surgery center?
Robert Noecker, MD, New Vision Cataract Center, Norwalk, Conn.: Denials obviously can lead to non-payment of devices. At a minimum, they increase the amount of money tied up in accounts receivable. This can affect cash flow, which can be problematic if there is no cash on hand to pay expenses.
This can affect the viability of the ASC and result in less profit for the owners. If denials are not caught in a timely fashion, the window for payment can close. Also if these are not monitored closely, repeat denials can occur on the same procedure with mounting losses if not corrected.
Q: What are some strategies your surgery center uses to deal with denials?
Dr. Noecker: We do regular audits to spot check payment for services. We try to do these on a monthly basis to ensure that if there are denials we either do what we can do to correct them or at least do not do more of the same procedures in the facility without an alternative plan for payment.
If a procedure is known to have been denied in the past, we try to obtain prior authorization from the insurer and while this does not guarantee payment, it increases the likelihood.
Also for some of the newer devices and procedures, the manufacturers have contracted with third parties to aid in prior authorizations or helping to clear up denials. We have found these to be very helpful in assisting with preventing and resolving denials.
Q: Do you think insurance companies will become stricter regarding claims in the future?
Dr. Noecker: Yes, it seems to be a growing trend that patients will bear more of the cost of procedures in the future. We see more resistance to getting paid with newer procedures or procedures that are out of the norm. It seems to take longer for the newer procedures to gain acceptance at the payer level compared to years past.
Q: What are some of the best value-added services for eye centers? What must they consider when adding these?
Dr. Gonzalez: Speaking from a perspective of a mainly general ophthalmology ASC, one must really look at the cost effectiveness of adding new services. Many centers have looked at adding treatments such as laser cataract surgery, endoscopic cyclophotocoagulation and other minimally invasive glaucoma treatments. As always, if a center can get its physicians to perform minor laser procedures at the center rather than in the office, that provides added income to the facility.
Q: Some centers are looking at bringing in retina procedures. What are the advantages and challenges to actually incorporating retina into ASCs?
Linda Phillips, Southgate (Mich.) Surgery Center: One of the biggest advantages is that it offers the opportunity to be a full-service ophthalmology center. This is an advantage in terms of marketing to patients and allows your center to offer comprehensive quality care. The other advantage is that for a lot of the retina procedures the reimbursement is higher, so it does help with your bottom line.
The biggest adjustment will have to be made to the staff's training; particularly, the nursing staff in the OR. They will have to have things ready for the retina surgeons, for which they will have to learn a new skill set. We bought new equipment for retina procedures, and we had the representatives here to train the staff. We also visited other retina surgeons to observe.
Steven Klein, CEO, Sheepshead Bay Surgery Center, New York: [Some challenges are] availability of operating room time as well as upfront acquisition cost of equipment, instruments and supplies and reimbursement rates. Other challenges are the need for retinal surgeons with volume and identifying types of retinal cases that can be performed in the ASC.
[However], payers will force it to happen because it's less expensive in the ASC. Also, with smaller gauge instruments, cases will be performed faster.
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Q: What are some of the challenges that ophthalmology centers face in the coming year?
Mark L. Gonzalez, MD, The Eye Center at MedStar, Washington (D.C.) Hospital Center: First, as in years past, the decreasing reimbursement has been and will continue to be a problem. With high overhead costs, many centers run on a relatively tight per case margin. Any decrease in this margin, when multiplied over the entire years' case load, may result in a significant fiscal stress and can shift the financial outcome of a center.
Q: In addition to reimbursement trends, claim denials are a big concern for eye centers. What effect do they have on your surgery center?
Robert Noecker, MD, New Vision Cataract Center, Norwalk, Conn.: Denials obviously can lead to non-payment of devices. At a minimum, they increase the amount of money tied up in accounts receivable. This can affect cash flow, which can be problematic if there is no cash on hand to pay expenses. This can affect the viability of the ASC and result in less profit for the owners. If denials are not caught in a timely fashion, the window for payment can close. Also if these are not monitored closely, repeat denials can occur on the same procedure with mounting losses if not corrected.
Q: What are some strategies your surgery center uses to deal with denials?
Dr. Noecker: We do regular audits to spot check payment for services. We try to do these on a monthly basis to ensure that if there are denials we either do what we can do to correct them or at least do not do more of the same procedures in the facility without an alternative plan for payment.
If a procedure is known to have been denied in the past, we try to obtain prior authorization from the insurer and while this does not guarantee payment, it increases the likelihood.
Also for some of the newer devices and procedures, the manufacturers have contracted with third parties to aid in prior authorizations or helping to clear up denials. We have found these to be very helpful in assisting with preventing and resolving denials.
Q: Do you think insurance companies will become stricter regarding claims in the future?
Dr. Noecker: Yes, it seems to be a growing trend that patients will bear more of the cost of procedures in the future. We see more resistance to getting paid with newer procedures or procedures that are out of the norm. It seems to take longer for the newer procedures to gain acceptance at the payer level compared to years past.
Q: What are some of the best value-added services for eye centers? What must they consider when adding these?
Dr. Gonzalez: Speaking from a perspective of a mainly general ophthalmology ASC, one must really look at the cost effectiveness of adding new services. Many centers have looked at adding treatments such as laser cataract surgery, endoscopic cyclophotocoagulation and other minimally invasive glaucoma treatments. As always, if a center can get its physicians to perform minor laser procedures at the center rather than in the office, that provides added income to the facility.
Q: Some centers are looking at bringing in retina procedures. What are the advantages and challenges to actually incorporating retina into ASCs?
Linda Phillips, Southgate (Mich.) Surgery Center: One of the biggest advantages is that it offers the opportunity to be a full-service ophthalmology center. This is an advantage in terms of marketing to patients and allows your center to offer comprehensive quality care. The other advantage is that for a lot of the retina procedures the reimbursement is higher, so it does help with your bottom line.
The biggest adjustment will have to be made to the staff's training; particularly, the nursing staff in the OR. They will have to have things ready for the retina surgeons, for which they will have to learn a new skill set. We bought new equipment for retina procedures, and we had the representatives here to train the staff. We also visited other retina surgeons to observe.
Steven Klein, CEO, Sheepshead Bay Surgery Center, New York: [Some challenges are] availability of operating room time as well as upfront acquisition cost of equipment, instruments and supplies and reimbursement rates. Other challenges are the need for retinal surgeons with volume and identifying types of retinal cases that can be performed in the ASC.[However], payers will force it to happen because it's less expensive in the ASC. Also, with smaller gauge instruments, cases will be performed faster.
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