News from the AOA's Blog

Edited by Chuck Brownlow, O.D., AOA Coding and Medical Records consultant

The darker side

AOA members and their staffs have sent hundreds of questions and comments to us through askthecodingexperts@aoa.org over the past three months, many of which focused on the significant reductions in Medicare reimbursements for retinal imaging. As we all know by now, a favorite old Current Procedural Terminology© (CPT) code, 92135, has been replaced by two new codes, 92133 and 92134. The change in codes would not have attracted much attention and may even have been appreciated if not for the additional news we received about the new codes; CPT classifies them each “unilateral or bilateral,” essentially meaning that if the code is used alone, without modifiers, the practitioner is paid the same, whether he or she completed the imaging on one or both eyes.  The third bit of news was that Medicare established relative values for the new codes that were nearly identical to the 2010 relative values for the old unilateral code, 92135. That change effectively set the value of each of the new services at half of the value of 92135.

We’ve already discussed the logic of how this all happened in earlier articles, e-mails, etc., so now it’s time to move on. What happens in CPT happens with input from providers, including ODs, but the process is not controlled by any one specialty group. Eye care providers are at the mercy of other specialties. CPT definitions are not created to advantage any one group; they are created to reflect what the CPT Editorial Panel feels best fits the entire health care environment in which each service is provided.

Similarly, when Medicare establishes values for the services it covers, it also receives input from providers of those services. You can bet that optometry and ophthalmology were very active in defense of the values of these new codes, especially given the change from unilateral to unilateral/ bilateral. White papers were written and provided, phone calls were made, meetings were attended, but in the end, fiscal reality prevailed. Utilization of imaging services has risen dramatically, meaning that Medicare’s payments for imaging services have risen directly. When a buyer of services sees rises in utilization and payments at a time when the buyer’s resources are decreasing, the buyer lowers the fee it offers for those services.

The brighter side

Of the 50 eye care services covered by Medicare and commonly provided by optometrists, the only codes that have lower values for 2011 than they did in 2010 are retinal imaging (92133 and 92134), limited and intermediate visual fields (92081 and 92082), and external photography (92285). The values of the other 45 codes increased by an average of about 10 percent. This, coupled with a 5.7 percent decrease in Medicare’s conversion factor, yields an expected overall increase in payments to optometrists of 2 percent over 2010. Optome-trists are among a group of very few Medicare providers expected to see any increase at all for 2011, with most providers facing overall decreases in payments for the services they provide Medicare patients.

The provider’s side

The American economy depends upon the rules of supply and demand, essentially reflecting the old concept of one person or entity offering goods or services to the public and another person or entity. The value of the good or service is determined by the provider and then either accepted, rejected or countered through an offer from the buyer. The same is true when referring to health care providers and health insurance companies. In nearly every situation, the provider is contracted with the insurer based on conditions, some of which refer to what the provider will be paid for services for the insurers’ subscribers. If the insurer offers less than the provider feels is appropriate, the provider doesn’t sign the contract and makes a counter offer, or simply rejects the contract. Medi-care is a little different, in that all the bargaining takes place on a very large scale and precludes any negotiating by an individual provider. But still, the provider decides whether to continue the contract with Medicare or to reject it.

This would be an excellent time for all optometrists to review every insurance contract currently in effect in the practice. First, how many of those contracts were renewed for 2011 (or simply overlapped into another year without renewal)? Second, of the contracts that are in force for 2011, how many include an across-the-board increase in reimbursements of 2 percent or more? My guess is few or none. Why is that? The AOA was active in fighting for fair treatment for optometrists in Medicare by working with Congress and the Centers for Medicare & Medicaid Services (CMS). Have you been as active in insisting on fair treatment with the other insurers you are contracted with or have you simply permitted the contracts to renew automatically, without so much as a review of the conditions of those contracts?

The AOA can and does help where it can and where it is appropriate to lobby Congress or to urge the CMS to treat optometrists fairly, but with all other payers, the negotiation must take place between individual providers and the insurance company. The AOA can meet with insurers and urge fairness and can provide information about the services optometrists provide and the importance of those services to patients’ well-being. But negotiations on behalf of single providers cannot be done collectively, by the AOA or any other membership group, it must be done individually, by each contracted doctor. 

With Medicare, it is pretty much a “take it or leave it” proposition. If you believe the reimbursements are below what you can accept in exchange for your services, you simply don’t renew your contract and you become a non-participating provider for your Medicare patients.

For other insurers, it often is a matter of negotiations. If you believe the reimbursements offered by the insurer are below the value of your services, you should contact the insurer two or three months before renewal, or before you sign the original contract, and negotiate for reimbursements that you need. Many providers do that with every contract prior to every renewal. 

It is not the fault of those providers, nor is the fault of the insurers, if your reimbursements are unsatisfactory. The laws of the United States and of each state leave it to the individual provider to ensure that his/ her reimbursements are acceptable for her/his services.

So, maybe you cannot fix the contracts that you’ve already signed for 2011, but this is definitely the time to prepare for 2012 by reviewing all current contracts and deciding which to accept, reject, or negotiate prior to renewal for 2012.

Once your strategy is established, it will be easy to consider, accept or reject any new offers you receive from other insurers. 

The tail can’t wag the dog unless the dog permits it.  It’s time to grab the bull by the horns and turn it a little, even if you cannot stop it in its tracks.