Ophthalmology Reimbursement Changes Coming in 2015

Like it or not, significant changes are coming to ophthalmology reimbursement in 2015. Some will affect the amount of money you make; others may even change the way you operate your practice.

Declining RVUs

The first change that could significantly affect your reimbursement is a devaluation of codes for retinal procedures endorsed by the American Medical Association (AMA)/Specialty Society Relative Value Scale Update Committee (RUC).

“RUC recommended an average cut of about 22 percent in our work RVUs (relative value units) and the Centers for Medicare and Medicaid Services accepted the recommendation,” explains ophthalmologist Rishi Singh, MD, Medical Director of Clinical Systems at Cleveland Clinic.

“Under the Medicare Physician Fee Schedule, reimbursement for cataract surgery has declined by $35. More intricate procedures, such as vitrectomy to repair retinal detachment, have decreased by as much as $417. These procedures are done for medical necessity, so we can’t stop doing them. But we may have to look for cost savings through development of more lean processes,” Dr. Singh says.

From bundles to episodes

Another reimbursement change that is coming in 2015 is a movement from bundled payments to episode-based care payments.

“As of now, surgical payments are bundled so that the physician is paid for the surgery and for any visits over a certain period of time during the post-op period. Under the new payment structure, post-surgery visits will be paid ad hoc on an as-needed basis, so there will be a significant decrease in the surgeon’s initial payment,” Dr. Singh says. “This might not be an issue for surgeons who follow their patient in the post-op period, but those who send their patients to an ancillary provider for post-op care will see a major decrease in their overall reimbursement,” he says.

The Medicare Payment Advisory Commission (MedPAC) is also considering reinstituting a least-costly alternative policy for drug plans. “The new policy would require physicians to prescribe the least expensive drug as a first-line therapy,” Dr. Singh notes. “In order to prescribe a more expensive drug, you’d have to show that the first drug failed as a therapy.” The American Society of Retina Specialists has sent a letter to MedPAC expressing concerns about payers dictating the type of drugs that are used for therapy and offering to assist with alternative methods for cost savings.

It pays to go electronic

Medicare is also getting ready to institute payment cuts for physicians who have not implemented electronic health records (EHRs).

“For some time, physicians have been given incentives to get them to migrate to EHR systems,” says Dr. Singh. “Although the number of physicians adopting EHRs has increased drastically over the last several years, ophthalmologists have been a little slower to adopt.”

In order to avoid the cuts, you must be able to attest to meaningful EHR use (e.g., ordering labs electronically, e-prescribing, offering a secure portal for patients to e-mail the physician). “If you don’t adopt an EHR and attest to meaningful use, you’re subject to payment cuts from Medicare,” Dr. Singh says. “The first cuts, which will begin in 2016, will be 1 to 2 percent, but they’ll increase over time. The good news is that if you do attest in 2015, you can still avoid the cuts for the following years.”