Upon completion of cataract or refractive (i.e. LASIK) eye surgery, a series of post-operative exams, evaluations and tests are required. This post-operative care can be performed by the ophthalmologist who performed the surgery or it can be sub-contracted to the patient’s optometrist or another provider. This type of arrangement is most commonly referred to as clinical “co-management”.
Co-management is the planned transfer of care during the global period from the operating surgeon to another qualified provider when clinically appropriate. Normally, the operating ophthalmologist makes arrangements before surgery to refer the patient to another ophthalmologist or optometrist for post-operative care with prior approval of the patient. According to data in Key Metrics: Assessing Optometric Practice Performance (2015 Edition), 12% of optometrist eye care visits are related to post-operative cataract and refractive surgery co-management. The physician or optometrist receiving the patient must be licensed to manage all aspects of the post-operative care, including the ability to diagnose potential complications that may require another operation.
OIG is Looking
Co-management of patient care has been targeted by the Department of Health and Human Services, Office of Inspector General (OIG), as a potential illegal kickback. Specifically, the OIG Fiscal 2003 Work Plan states that the OIG “will determine if relationships between ophthalmologists and optometrists violate anti-kickback laws.” The OIG will examine arrangements where optometrists refer surgical cases contingent upon the surgeon’s referral of the patient back to the optometrist for post-surgical care so that the optometrist shares in the global surgical fee. In addition, the AMA and the American College of Surgeons have expressed disapproval of co-management arrangements that are driven by economic considerations.
It’s common for an optometrist to refer their patients to an ophthalmologist for eye surgery. Then, the ophthalmologist will contract with the referring optometrist to perform the post-op care for that patient. This cross-referral relationship causes the need to ensure payments to and from referring physicians to be strictly at fair market value (FMV) and that the post-op procedures are commercially reasonable.
If the patient is covered by Medicare and is getting standard cataract surgery with a traditional lens, then the co-managing provider who is performing the post-op care can bill and collect from Medicare for their portion of the global reimbursement for the covered cataract procedure.
However, if a patient elects to have a laser-assisted cataract procedure and a premium lens, which is not covered by Medicare, then the patient will normally pay out-of-pocket for this upgrade. In such case, the operating ophthalmologist may require certain additional post-op care, over and above that which is covered by Medicare under a normal cataract surgery case.
The physician performing the surgery will bill and collect from the patient for the elective (non-covered) upgrades and also pay the co-managing provider a fair market value fee for the additional post-op care.
As such, it is vitally important that the post-op co-management fee paid by the surgeon and collected by the referring optometrist is FMV. It is advisable to have a third-party appraiser estimate the fair market value of the post-op procedures and protocols that the operating ophthalmologist requires[1]. A qualified appraiser will estimate a fair market value of the professional time, overhead and administrative time incurred in each post-op visit. Each post-op visit typically includes a visual acuity test for near and distance vision, a tonometry test and slit lamp examination (explained later in the report). However, the post-op care varies based on different patient outcomes and could require additional post-op visits and additional tests and examinations.
In addition, if the surgeon is requiring additional procedures and protocols and or additional post-op visits, then this also must pass a commercially reasonable (i.e. clinically necessary) examination. A third-party appraiser/consultant should be hired to perform this analysis.
The American Academy of Ophthalmology (AAO) and the American Society of Refractive & Cataract Surgery (ASCRS) have published guidelines for health care providers considering co-management relationships. Both AAO and ASCRS believe co-management is ethical and appropriate in the right circumstances and certain requirements must be met.
The Society for Excellence in Eyecare (SEE), an organization consisting of both ophthalmologists and optometrists, believes that patients should control the co-management decision, subject to the surgeon determining that the decision is in the patient’s best medical interest and they also recommend that post-operative care by a referring optometrist should only occur when the patient is fully informed about co-management.
Chris David
303-918-3607
[1] The operating ophthalmologist has the ultimate responsibility for the preoperative assessment and postoperative care of the patient, beginning with the determination of the need for surgery and ending with completion of the post-operative care. The post-operative period is the time in which most complications occur and within which stable visual function is achieved. The operating ophthalmologist has an ethical obligation to the patient that continues until post-operative rehabilitation is complete.
The Physician Payment Sunshine Act puts pharmaceutical and medical device companies under intense scrutiny and exposure. Compensation paid to healthcare professionals (“HCP”) and healthcare institutions for various services, such as speaking, training, product development, R&D, advisory board service and consulting must be at fair market value (“FMV”) or risk being in violation of the Federal Anti-Kickback Statute.
