Prepare for the challenges ahead

Here’s a look at the current and emerging obstacles in ophthalmic practice management.

Prepare for the challenges ahead

Here’s a look at the current and emerging obstacles in ophthalmic practice management.

By Elizabeth Holloway, COE and Andrew Maller, COE

Considering the increasing regulatory requirements and ever-changing technologies the field of ophthalmology is experiencing at seemingly lightning speed, physicians may wonder, “Is my practice aware of and focused on the most important changes occurring in healthcare today?” These changes have increased the demands and constraints on physicians and administrative staff. Practices today have to stay up to date, be aware of their surroundings, and develop strong leadership teams to deal with an ever-changing landscape.

In this article, we’ll examine some critical areas that practices should focus on today to ensure they are prepared for the future.

Medicare payment reform

In late April, CMS released the proposed rule on how the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) will be implemented over the next few years. We now are beginning to get a clearer idea of MACRA’s impact on how doctors will be reimbursed from Medicare beginning in 2019. The most notable aspect is the long-awaited repeal of the sustainable growth rate formula, which prevented the scheduled 21% reimbursement cut to Medicare payments. Even though the new payment system does not officially begin until Jan. 1, 2019, the scoring system that is described below will be based on 2017 performance.

MACRA establishes two payment tracks, and all providers will fall into one of them. The first track, known as the Merit-based Incentive Payment System (MIPS), will combine elements of Meaningful Use, the Physician Quality Reporting System (PQRS), and the Value-Based Payment Modifier (VBPM). It also adds a new program, Clinical Practice Improvement Activities, which will be focused on ways to improve care coordination, beneficiary engagement, and patient safety. These elements will be scored together to determine the payment schedule for a provider or practice. This will be the default track for eligible professionals unless the practice is already part of a qualified Alternative Payment Model (see below).

Beginning in 2019, MIPS will score eligible professionals based on a composite score determined by assessing a practice’s performance in the four categories noted above. (The composite score will be a number from 0 to 100.) Depending on where eligible professionals fall on the scale, they would receive a negative, no adjustment or a positive adjustment to their Medicare Part B payments.

The second track of MACRA is known as the alternative payment models (APMs) track. Eligible professionals who receive at least 25% of their Medicare Part B payments through a qualified APM (such as an accountable care organization) fall under this track. Eligible professionals who qualify for the APM track will receive an annual 5% lump-sum bonus payment in addition to being excluded from the requirements of MIPS.

Although MACRA does not technically begin until 2019, it is critical to remember that 2017 will be the performance year that will determine the payment adjustment for the first year of this new program. With that in mind, practices should continue their pursuit of successfully meeting the requirements of Meaningful Use, PQRS and the VBPM system in addition to using technology to ease the challenges of data reporting.

We do not have the space in this article to go into great detail about every element of the MACRA law. It is critical for practices to do their own research to stay up-to-date as more details about MACRA are revealed. For practices looking to learn more, watch for resources provided by trade associations such as ASCRS or AAO in addition to information provided by CMS.

Emerging commercial payer trends

As regulations of the Affordable Care Act (ACA) take shape, commercial payers continue to respond by altering the way they do business. In many instances, these changes have had a negative impact on practices. In certain geographical areas, practices continue to encounter the narrowing or re-alignment of provider panels. They’ve also experienced increases in record requests before claims are paid, causing delays in payments and a slow-down in reimbursement. Billing office staff have experienced claims denials if payers have not aligned ICD-10 codes with ophthalmic tests or procedures. For example, several practices recently received the following notifications from a specific payer:

    • The Provider Payment Integrity department determined that diagnosis code E11.329 was among codes listed in error as manifestation codes when rule 027-06 for Manifestation code logic was converted from ICD-9 to ICD-10.

    • All of our prepay rules regarding this logic have been corrected and an Incorrect Payment Audit Request (IPAR) is being sent to correct any claims that were denied in error.

    • In addition, the Code Logic team reviewed the denial and determined that the ICD-10 Coding Guidelines indicate to “use additional code” under category E11. It states to “use additional code to identify any insulin use (Z79.4).”

    • An insulin use code should be used when it applies and could trigger a denial if not included.

To ensure these issues do not adversely impact a practice, consider these action items:

    • Stay connected to commercial payer trends. Use industry ListServ opportunities. The AAO and ASCRS can help connect physicians and administrators with payer issues. If your practice struggles with an unreasonable amount of records requests from a particular payer, connect with other practices that experience the same problems. If a group of practices can demonstrate that the payer is causing an undue burden on their practices, they may be able to affect change in the payer’s policy.

    • Develop relationships with commercial insurers. Your practice may consider setting up meetings with a payer’s local representatives. Find a contact person who can help your practice navigate through billing issues. Try to find common ground, instead of seeing third-party payers as opponents.

    • Evaluate payer contracts periodically and understand how the contract impacts practice income.

    • Immediately notify payers when ophthalmic CPT codes are not accurately linked to ICD-10 codes.

Accelerated adoption of technology

Technology itself is not a negative — many recent advances have enabled the industry to continually improve patient care. However, adopting technology can alter and sometimes even impede the ability to do business. So, practices have to be strategic in how they implement technology and in what they choose to implement.

Before investing in new equipment or IT services, practices must determine if they are making the best decisions by answering these questions:

    • How will adding this new technology impact patient care?

    • What is the financial impact this purchase will have on the practice? Has a feasibility analysis been conducted?

    • When will the practice meet the break-even point and start generating revenue?

    • What will be the impact on practice operations when the new technology is employed?

If a new technology makes business sense, the physician and administrative leadership need to develop a plan to implement the new technology into the practice. For example, if a practice wants to install kiosks for patients to complete an automated check-in process, the practice should determine if its patients will benefit from the technology, determine the break-even cost of the program and develop a realistic time-table to implement the software with patients and staff. By introducing the technology in a step-by-step, organized fashion, the practice will see that new tools can improve the patient experience and increase the practice’s bottom line.

What successful practices are focusing on in 2016

Ophthalmic practices face no shortage of challenges, and this spate will likely continue into the future. Success in this environment requires taking a proactive approach. Practices that do will probably have some common characteristics, including:

    • A desire to stay up to date on new and existing legislation. It is imperative that practices stay connected to industry resources, particularly as the details of MACRA continue to unfold. Likewise, practices want to pay close attention to changing local market trends with commercial payers and health systems.

    • A focus on patient-reported outcomes and satisfaction. One link connecting these issues is a strong focus on improved patient outcomes and satisfaction. Practices must be able to demonstrate (through technology) that they are meeting this objective.

    • A business model that can adapt to change. It is clear that one of the top priorities from Medicare, commercial payers and health systems is a mandate for practices to provide higher quality care at a lower cost point. Those practices able to demonstrate a commitment to meeting this objective will be seen favorably.

Strong leadership

The need for strong leadership at the physician and administrative levels is a given.

Practice leaders must work collaboratively to attack the obvious obstacles, while at the same time staying focused on what looms over the horizon. OM

About the Authors

Ms. Holloway is a senior consultant with BSM Consulting in Clearwater, Fla. Her current certifications include Professional in Human Resources (PHR) and Certified Patient Service Specialist (CPSS).

Mr. Maller is a principal and consultant with BSM Consulting, an internationally recognized health-care consulting firm in Incline Village, Nev., and Scottsdale, Ariz. For more information, visit