As we are aware, reimbursements for procedures, exams and diagnostic tests are being cut in the retina world. Financial viability for retina practices is at stake, so it is vital for practices to adapt to current conditions and learn to make changes.
Because of these factors, a close look into the management of retina practices is more important than ever. In training, most of us were not taught much with regards to the business of medicine. What we have learned comes from our peers, colleagues and, mostly, experience. This article offers ideas to improve financial viability in retina practices — without compromising patient care.
Several areas can be evaluated for potential for improvement (see “Ways to improve financial viability,”). Opportunities to strengthen financial viability and maintain great patient care include: changing front desk policies; improving preauthorization rates; better coding; managing inventory; and monitoring staffing.
Below, I discuss each of these issues and ways in which my practice improved in these areas.
We recently changed our policy for collecting payments during office visits. Previously, billing patients for their copayment and deductible was an acceptable policy. Now, it is harder to collect fees post-visit. As a result, during the past two years, our front desk started collecting copayment, deductible and amount owed before patients check out. Similarly, verifying patient benefits before appointments has made collecting a seamless process and has increased collections.
Another concern is outstanding balances. Despite our best collection efforts, patients sometimes have large balances. Our financial administrator reviews the accounts receivable on a regular basis. Previously, we asked patients at check-in to pay their outstanding balance at their current visit; they often did not bring the means to do so and felt offended when asked to pay. To avoid this situation, we initiated a policy in which we call patients a day prior to their appointment and notify them that their balance is due at their appointment. This change has helped our staff in collecting payment and avoiding hostile conversations with patients.
Practices need to make changes to better ensure payment for services, especially for patients in skilled nursing facilities and for treatment preauthorization from insurance companies.
Practices treating patients in a skilled nursing facility are limited by consolidated billing. Of note, Avastin (bevacizumab, Genentech) is the only anti-VEGF intravitreal injection included in consolidated billing.1 Therefore, without an agreement in place, the nursing facility will not reimburse the practice for the cost of Eylea (aflibercept, Regeneron) or Lucentis (ranibizumab, Genentech). This can result in lost revenue to a practice.
To avoid this situation, our practice contracts prior to treatment with skilled nursing facilities, which commit to paying for these services. Despite these measures, there is still a risk. Patients who reside in a nursing home can have a sudden change in health, requiring transient increase in care. They are often moved within their own facility to “skilled nursing.” If this change is not recognized by the practice, reimbursement can be denied.
Many more insurance companies now require a preauthorization for procedures and medications. In this era of intravitreal injections for AMD and diabetic retinopathy in which patients often receive bilateral injections every few weeks, these appointments are made several weeks in advance to accommodate patient and family schedules. If a preauthorization is missed and a procedure is done, practices risk a loss of reimbursement. To reduce this risk, our office has a designated staff member responsible for completing preauthorizations and rescheduling patients should there be a delay in the process. Also, we utilize sample programs if a patient is already in the office without an authorization for an intravitreal injection.
Due to the high cost of injectables, a large sum of the missed revenue in practices is comprised of the consolidated billing of skilled nursing facilities and missing preauthorizations. With the above steps, some of this revenue can be recovered.
Every year, small changes to coding are made, and missing these changes can cost a practice. There are three options for coding:
- Outsourcing to a third-party. These often have a 30% collection fee but can catch errors and often save time for you or your staff.
- In-house coding department. This saves time for you and your scribe but is often limited to large practices due to staffing costs.
- Staying up to date on coding changes. This reduces the chance of missing modifiers, recent changes in coding, etc. While this takes time away from staff, it is a popular option among small practices for saving on the cost of a full-time coding staff member. Ways to stay up to date on coding include the AAO coding guide and the ASRS Business of Retina Meeting.
With the cost of medications, supplies and equipment increasing, keeping track of your inventory is essential.
As costs increase, it is our responsibility as the consumer to consistently check prices. For example, for years we ordered vancomycin and ceftazidime from a large distributor. Due to a recent shortage, we were forced to look locally at our regional hospital pharmacies. The hospital prices were surprisingly cheaper. The same applies to fluorescein dye, equipment for injections, lasers and eyedrops. In this financial environment, it is wise to shop around and be aware of new options, which helps to reduce costs.
Ways to improve financial viability
- Collect copayment, deductible and amount due at the time of visit by verifying patient benefits before their visit.
- Regularly check accounts receivable.
- Call patients about large outstanding balances prior to the next appointment.
- Get insurance authorization, if needed, prior to appointment.
- Contract with skilled nursing facilities to ensure payment of services.
- Stay current with coding changes.
- Shop around for supplies, equipment and medications.
- Prioritize inventory control of injectables.
- Retain and cross-train staff, and assess staff satisfaction regularly.
- Treat your patients with respect and kindness.
On a larger scale, the cost of intravitreal medications, managing drug inventory and upfront cost of drugs is a hot topic. In 2010, Medicare paid $2 billion in Part B costs for intravitreal injection treatments,2 and this number is on the rise. It is estimated that the cost of aflibercept and ranibizumab account for 12% of the Medicare Part B budget annually. By 2012, this number had reached $5.6 billion.3
Inventory control is crucial; it helps determine when to order more medication and protects profits. The cost of each medication is around $2,000; if one vial is lost or expires, it’s a large expense. Inventory control consists of several parts (see “Inventory control tips,”). These measures have helped keep us financially viable.
While we work hard to keep up with a busy practice, it is easy to forget that the livelihood of our clinic and operating room comes only with great staff. It has been shown that one retina specialist requires approximately eight full-time employees. We find this to be accurate and sustainable.
However, one key aspect that we have maintained in our practice is cross-training our staff. While it would be a luxury to have a dedicated photographer, surgery scheduler, injection technician, etc, we found that these roles were often underutilized at our clinic. Cross-training our staff prevents the above and keeps the clinic moving on days when staff take vacation or a sick day. Each technician is trained to work-up patients, take photographs, prep for injection and lasers and aide in surgery scheduling. Also, most of our technicians are trained as scribes. Similarly, our front desk staff is cross-trained to check-in patients, answer phone calls, make appointments, handle collections and file and submit claims. This has been a critical aspect of our practice and has worked well for our staff. Each member is busy at all times, understands their value in the practice and has a place to continue moving upward in the system.
Inventory control tips
- Keep a patient log. This includes patient name, date of procedure and the eye injected.
- Keep an inventory log of medication. There are many ways to do this; our practice uses a barcode system.
- To protect your medications, keep them in a locked storage area at their ideal temperature.
- Document wastage, in case of an audit. Our EMR is set up to ask for amount of wastage in the procedure note.
- Balance inventory on a regular basis — our practice does this weekly.
Retaining personnel is a crucial part of staffing. There is a high cost to losing staff, and unfortunately that loss is sometimes inevitable. Over the past few years, our practice has changed the candidates we interview and hire. While it is easy to bring on candidates who are overachievers and are looking for a temporary position while applying to medical school, nursing school, etc, we have changed our methods to search for candidates who wish to make our practice their career. We encourage them to obtain certification and reward these accomplishments with salary increases. Throughout training, they are advanced to new instruments, procedures and levels within the practice. Having monthly meetings to reassess their satisfaction is helpful.
Some practices opt for an anonymous suggestion box, while others promote team activities and social outings. Whichever method you choose, it is important to realize that staff happiness is instrumental to running a smooth practice.
We should run a practice that we would enjoy going to as a patient. Patient happiness is important, especially as reimbursement and outcomes are linked to their satisfaction.
Since your lobby is one of the first things visitors will see, make sure it is calm and puts them at ease. For example, elegant artwork or decorations and nice coffee table books are a good start. A soothing scent, such as lavender, helps ease the nerves. Light music or TV is a good distraction from the wait, but avoid TV channels with news or political discussions.
Our dilating room has dim lighting, coffee, a refrigerator with water bottles and some light snacks. Gentle reminders to turn off cell phones should not be overbearing or sound negative.
We consistently work on improving our patient wait times and patient experience. Talk to your patients as people, not just the next injection/procedure subject. Be sure that your staff does the same. Get to know their family, their vacations and what may be going on in their lives. Treat your patients like you wish to be treated by your physicians.
While practicing in this time of decreasing reimbursements is challenging, we must adapt. With some changes in your practice, you will likely improve your financial viability while continuing to provide great patient care. It remains a privilege to practice retina and take care of these patients. OM
- Corcoran S. Payment for nursing home patients. Ophthalmology Management. 2009;13:25.
- Dugel PU, Tong KB. Development of an activity-based costing model to evaluate physician office practice profitability. Ophthalmology. 2011;118:203-208.
- Patel S. Medicare spending on anti-vascular endothelial growth factor medications. Ophthalmol Retina. 2018;2:785-791.