Cataract
April 2022

by Ellen Stodola
Editorial Co-Director

According to Tal Raviv, MD, comanagement has been a part of ophthalmology for more than 40 years as a means to coordinate surgical ophthalmic care among different provider types. “It has regained attention and scrutiny with the growth of refractive cataract surgery,” he said. “But today’s practice environment is quite different from the past.”

Dr. Raviv noted some big picture trends in cataract surgery. As more baby boomers hit their cataract years and as the procedure is performed at a younger average age, the volume of cataract surgery is projected to steadily grow for the next few decades. “At the same time, cataract surgery is becoming concentrated to fewer high-volume surgeons due to decreasing third-party reimbursement and rapid refractive IOL innovation that requires significant capital investment in diagnostics and more specialized skills,” he said. “These growing surgical practices rely on a team approach for providing high-level surgical and postoperative care. This is a long-time practice in many other surgical specialties from cardiovascular to transplant surgery.”

For covered medical procedures, third-party reimbursement (such as Medicare) has coding provisions to allow each provider to bill for surgical or postoperative care, Dr. Raviv said, and for non-covered elective services, such as LASIK or the refractive surgery component of cataract surgery, cash payments are made by the patient.

Robert Maloney, MD, said that the key issue is that the comanagement fee has to be proportionate to the amount of postop work required. There are two levels of comanagement in cataract surgery; the first is for standard cataract surgery, and the second is for cases with an advanced technology, such as the femtosecond laser or an advanced technology IOL.

For standard cataract surgery, with Medicare, Dr. Maloney said the postop care fee is 20% of the total surgical fee. If doctors are comanaging a Medicare cataract, the doctor bills Medicare for the surgical care only using the -54 modifier, and the comanaging doctor bills for the postop care using the -55 modifier. The comanagement fee covers the first 90 days of care after the surgery.

“You have to educate the patients before surgery so they understand the roles and that they have a choice about where their postop care is done.”

Robert Maloney, MD

Advanced technology IOLs require more work postoperatively. “AECOS [American-European Congress of Ophthalmic Surgery] is studying the postoperative work required by advanced technology lenses,” Dr. Maloney said. “Our preliminary finding is that these lenses require significantly more work postoperatively.” The work includes additional visits related to optimizing uncorrected vision or performing enhancements.

For patients who have advanced technology lenses who are comanaged, Dr. Maloney said it’s customary for there to be an additional comanagement fee paid to the doctor who is doing the postop care to cover the extra work involved. “The key issue in terms of best practices is that additional fees should be commensurate with fair market value of the extra work required,” he said.

Dr. Raviv uses comanagement in his practice, though he noted that it’s only a small part. “We do work with some community optometrists and medical ophthalmologists who have extensive experience in delivering refractive postop care,” he said. “When initially constructing a comanagement framework for our practice, I set out to exceed any compliance hurdles associated with historical comanagement arrangements.”

Dr. Raviv noted that most refractive cataract surgical services involve multiple fees: a professional fee for the surgical provider, non-surgical eyecare provider, and facility charges. “Historically, one global fee was collected from the patient, with the surgeon’s practice later ‘passing on’ payments to any outside parties,” he said. “With today’s increased regulatory scrutiny, enforcement of anti-kickback statutes, and poor optics of MDs making payments to outside ODs, many of these older practices are no longer tenable.” He added that it’s important for individual practices to seek guidance from consultants and/or lawyers to construct their own collaborative care agreements. But he did note four guiding principles: patient choice, price transparency, fair market value, and payment separation.

Dr. Raviv’s first comanaging arrangement was with an experienced comprehensive optometric group that was cash pay (did not contract with any third-party payers). “They told me what their charge was for their package of postoperative refractive cataract services. This was a fair price, and we started breaking down our own refractive fee structure,” he said. At booking, patients were presented with a written invoice showing the price of surgical care, postop care, and facility. They were also given a choice of postop providers—either the internal care team or their optometrist. “We then collected only the surgical professional fee (or surgical and postop fee, if patients chose), with the patient paying their ODs directly on their first postoperative visit,” he said.

This payment plan did work, but Dr. Raviv noted that he had some problems. A few patients, particularly those who scheduled their surgeries months after the booking visit, would forget about the postop services payment when seeing their optometrist, creating unnecessary friction. It was also hard for the optometric practices to keep track of which patient had what procedure, when, and how much they owed.

To try to address some of these issues, Dr. Raviv noted the utility of CoFi. “In seeking to follow all of the best practice guidelines, and with the steady influx of new IOLs with different prices, different refractive packages, and different postoperative options, our pricing paperwork kept getting updated and unmanageable,” he said. “Also, payment separation was creating confusion instead of simplicity and affecting the patient experience.”

Dr. Raviv co-founded CoFi, which is a cloud-based payment and reporting technology for elective medical procedures (ophthalmology is the initial focus) that allows for simple, compliant, multi-party payments.

With CoFi, there is an initial setup, where all the providers are onboarded—the surgeon(s), the ODs, the facilities, and even anesthesiology (for RLE or self-pay). Then the practice’s refractive packages are set up. “During surgical booking, it’s as simple as a few clicks to present a patient with a complete, detailed, multi-party invoice of their upcoming procedure,” he said. “With one credit card ‘swipe,’ the patient is able to make direct payments to each of the providers.” The digital invoice can also be emailed to the patient, who can then make a secure payment on their smartphone or computer on their own time.

“My practice has been using CoFi for more than a year with great feedback,” Dr. Raviv said. “The optometrists love the reporting dashboard to track their patients’ booking, chosen refractive package, payments made, and dates of upcoming surgery. Facilities are also able to remove the pain point of same-day elective IOL/femto payments, which requires continued training of front desk staff and can still lead to patient confusion, dissatisfaction, and even case cancellation.”

CoFi is now being utilized by many practices of all types and sizes around the country, he added. “For collaborative care to continue in ophthalmology and optometry, we must all strive to do so with the utmost transparency, compliance, fairness, and clarity,” Dr. Raviv said.

Dr. Maloney noted that comanagement is popular, and he sees it as the way of the future because “the way to run a healthcare system is to have everyone working to the highest level of their ability.” In general, he said this means that you want surgeons doing surgery and people who are experts at eye exams doing postop care. Traditionally, the surgeon has been responsible for preop, surgery, and postop care. “The surgeon doesn’t have the time to do enough surgery to be an outstanding surgeon,” Dr. Maloney said.

He sees more and more centers around the country where surgery is performed and postop care is delegated to other providers, within the practice or in the community.

Dr. Maloney likened this shifting mindset to the shift away from ophthalmologists prescribing glasses and contacts, with this being done more by optometrists or other personnel in the practice.

“The last 4 decades have seen a gradual shift toward ophthalmologists focusing on diseases and surgery and optometrists focusing on primary eyecare,” he said.

Dr. Maloney noted the importance of a conversation early on. “The key for patient acceptance is to explain the process of postop care ahead of time. You have to educate the patients before surgery so they understand the roles and that they have a choice about where their postop care is done,” he said, adding that it’s important that patients sign transfer of care forms if they are choosing to see a different physician for postop care.

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About the physicians

Robert Maloney, MD
Maloney-Shamie Vision Institute
Los Angeles, California

Tal Raviv, MD
Eye Center of New York
New York, New York

Relevant disclosures

Maloney: None
Raviv: CoFi

Contact

Maloney: rm@maloneyvision.com
Raviv: TalRaviv@EyeCenterofNY.com