ecl 1st issue

F A L L 2 0 1 5

TURBOCHARGE YOUR ASC’S PRODUCTIVITY & VALUATION

EYES OPEN:• WIN LIKE WARBY• DOUBLE YOUR DISPENSARY DOLLARS

HOW TO:• GET YOUR WAY

WITH A PAYER• REV UP YOUR RCM• MARKET TO NEW

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LL 2015

ECL-COVER-7.625x10.5.indd 1 10/5/15 1:31 PM

Optical Shop5 Double Your Dispensary Dollars 9 Moves Your Optical Manager Should Know

8 Advice for ECP Entrepreneurs Improve your practice’s customer service

with a 10-minute stroll

12 Wanna win like warby? Here’s how to adapt the breakout

company’s marketing strategies to your optical’s local market and business model.

WASHINGTON WATCH18 What the 2016 Medicare Physician

Fee Schedule Has In Store For You

20 Take the Long View What you need to know today to forge your

practice’s fi nancial future.

24 How To Get What You Want from Payers Discover 13 contract questions that

protect your profi ts

Avoid these 7 revenue-busting negotiation mistakes.

28 Revenue Boost Front desk and patient statement

strategies that pay.

HIT Help36 Crucial Questions to Ask Your EHR Vendor38 Quick-Start Guide to EHR Geek Speak39 ECP Gains 41 Percent ROI on EHR Investment

departments70 Eyes on Research Drops that dissolve cataracts? We’re closer

than you think.

74 Last Look Future’s So Bright … Corrective Lens

Revenue Growth in the U.S.

inside

41 New Rules for Compliance Survival

Master the Stark Swamp, the Sunshine Act, the PUF Data Dump & Unsafe Harbors.Plus, when auditors attack, you’ll have a game plan.

54 Focus: Ophthalmic ASCs

30 ways to boost productivity and profi tability.Plus, the latest on MU penalties, valuation and more.

features

60 The Path to ICD-Zen

Master the documentation techniques that get your vision care claims paid under ICD-10.

2 E Y E C A R E L E A D E R S

EYE CARE LEADERSFALL 2015

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Meet Some of the Experts in This Issue …

editorial erin Masercola, Phd Editor Nathan adamus Art Director Brad Crowder Art Director

CoNtriButorsKara Hiltz, Kristin Hollering, Jay Lodhia,

Michelle Stone, Nichol Wills

Editorial, Production & Sales Office2222 Sedwick Dr., Durham, NC 27713

Eye Care Leaders is published quarterly in Spring, Summer, Fall and Winter

PostMaster: Send address changes to 2222 Sedwick Dr., Durham, NC 27713.

© 2015 by Eye Care Leaders. All rights reserved. Reproduction of any material from this issue in whole or in part is strictly prohibited without written consent

from Eye Care Leaders.

our MissioNEye Care Leaders is your source for everything you need to know to run the business side of your ophthalmology or optometry practice.

We slog through the heavy reading and conference sessions for you and break them

down into short, plain-English bits that you can skim in just minutes a day. Our richly-sourced editorial content links you directly to the best expertise available for deeper research as you

manage your vision care practice.

Visit our Blog at http://www.eyecareleaders2020.com

@masercolawrites

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All Eye Care Leaders content is for informational purposes only, and is not legal advice or a substitute

for legal counsel. There can be no warranty or responsibility by Eye Care Leaders as to the legality,

completeness, or technical accuracy.

FALL 2015VOL 1, ISSuE 1

Barbara Cobuzzi brings skills she originally learned as an industrial engineer to RCM. She is President of CRN Healthcare Solutions in Tinton Falls, NJ and she holds numerous coding, billing, and compliance certifications.

Jennifer ecklund is a health care attorney in Dallas. She has represented health care providers in litigation brought by private insurers. She spoke at the American Health Lawyers Association Annual Meeting.

Bill Gerber is Creative Director of Optical Marketing Group, or OMG! He spoke at Vision Expo West.

Melody irvine is a practice management consultant with more than 30 years experience in health care. She has numerous coding and billing certifications, and is an AudioEducator speaker.

Joy Gibb, aBoC has managed an independent retail optical in Bountiful, utah and now runs her own business—Eyes of Joy Mobile Optical Service. She spoke at Vision Expo West.

Mark Johnson, ldo, aBo, NCle is Director of Optical Services at Virginia Eye Institute and is a regular speaker at national conferences.

Maggie M. Mac is a coding and billing consultant with ophthalmology expertise and multiple certifications. She is a nationally prominent speaker.

Wayne Miller, esq. is a founding partner of the Compliance Law Group in Los Angeles. He handles health care compliance for clients nationwide.

Valerie Manso, aBoC, FNao is President of a training and development company specializing in the ophthalmic industry. She spoke at Vision Expo West.

attorney robert Penezic leads a new HHS OIG litigation team that focuses on physicians. He spoke at the American Health Lawyers Association Annual Meeting.

Jeffrey Restuccio, CPC, CPC-H, MBA teaches documentation, coding, billing, and compliance at eyecodingforum.com.

sherrie rogerson is Senior Director of Corporate Accounts at REM Eyewear. She has more than 25 years experience in the optical industry and spoke at Vision Expo West.

steve Verno is a billing, coding, and A/R recovery expert. He is a nationally known writer on practice management issues, and a speaker on AudioEducator.

Nichol Willis is a licensed optician with current ABO and NCLE certs and EHR expertise. During her career she has worked as an optical manager with a leading retailer and led multi-location private opticals.

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With fresh news and analysis every weekday, Eye Care Leaders is your source

for everything you need to know to run the business side of your practice.

We slog through the heavy reading for you and break it down into short, plain-English bits that you can skim in just minutes a day.

OOur richly sourced editorial content links you directly to the best resources available

for deeper research as you manage your ophthalmology or optometry practice.

Follow us @MasercolaWrites

4 e y e c a r e l e a d e r s

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OPTICAL SHOP ECL

Is your optical shop making less for your practice than you’d like? A crucial conversation with your optical manger can help you work together to identify improvement opportunities and ways you can profit more than you are now.

1. Goal’s and KPIs. Some optical managers report that their doctors don’t seem to have goals for the dispensary or even think about it much. “I worked for a doctor whose goal was for everyone to come in every day to work, and that was it,” quips Sharon Carter, an optical manager and consultant who spoke at Vision Expo West. (Carter’s advice to managers: Set the shop’s goals yourself and present them to physician owners.)

As a physician owner, are you clear on what metrics your practice is using to measure success in your optical shop? Is your optical manager clear on what your goals are?

2. Methods for forecasting which frames will sell best in your practice and at each location (if you have multiple sites). What tools does your optical manager use in addition to talking with reps about frames that move well in your region? Has he tried zip code analysis or asking your lab what styles move most?

3. Number of vendors. Too many vendors is an all-too-common revenue buster.

When Mark Johnson first began managing optical shops at Virginia Eye Institute’s seven locations, they had 45 vendors total. Now they have 12, and do much better financially, he told an audience of optical managers at Vision Expo West.

A single location needs about eight vendors, Johnson estimates. Some experts recommend as few as three to five if you serve a market with lots of seniors who are likely to choose similar, conservative styles, says Robert Swanland, a POS software expert.

If you limit the number of vendors you work with, your optical manager has the bandwidth to negotiate good terms with each and to draw up written partnership agreements that protect your practice, just as you do insurance contracts, Johnson observes. You also set yourself up to negotiate volume discounts and you simplify your bill paying, says Sherrie Rogerson, a former optical manager who now works with REM Eyewear.

4. Criteria for vendor selection. Some criteria are givens, such as quality, service, delivery, warranty, return policy, rep service, and ease of order, Rogerson says. You can negotiate criteria such as discounts, shipping costs, and marketing assistance to benefit your practice.

Double Your Dispensary Dollars9 Moves Your optical Manager should Know

What To Do When Your Optical Manager Is Costing You MoneyIs your practice’s optical dispensary profiting as much as it possibly can? If not, training for your optical manager on inventory management, financial analysis, spreadsheet jockeying, and coaching sales teams can pay off big.

Does your optical manager resist training and coaching? Then it may be time to find a new one. One practice Sharon Carter consulted with saw its monthly optical dispensary revenue increase $25,000 once they replaced the manager.

Tip: If you don’t know whether your practice is making one or more of these revenue-generating moves, ask your optical manager. Begin each point with “Tell me about our optical’s ...” If your manager is effective, many of these things are already on your manager’s radar. If you show respect for what’s being done already, your manager will be more open to your suggestions and coaching.

EYES OPEN $With fresh news and analysis every

weekday, Eye Care Leaders is your source for everything you need to know to run the

business side of your practice.

We slog through the heavy reading for you and break it down into short, plain-English bits that you can skim in just minutes a day.

OOur richly sourced editorial content links you directly to the best resources available

for deeper research as you manage your ophthalmology or optometry practice.

Follow us @MasercolaWrites

f a l l 2 0 1 5 5

Dispensary Dollars.indd 5 10/5/15 11:15 AM

5. How many frames you carry and why. Frames typically are 43 percent of a practice’s expense and 30 percent of revenue, Johnson notes, citing Vision Monday stats.

Limit the number of frames you carry. You should have a selection suffi cient to move inventory at your location, but not so many that you’re tying up revenue unnecessarily.

Larger locations can handle 1000 frames, experts say. Small locations should carry around 750. Some opticals in particular markets with lots of seniors can profi t very well with as few as 600, says Swanland.

6. Turn ratio. Frames that don’t have an inventory turnover ratio of three or four are costing you money and you need to swap them out for frames with potentially higher turns, says Mark Johnson.

The exception is high-end, luxury frames, which will have lower turns in most places. It’s strategic for your optical shop to carry a few lower-turn frames if they move in your market and make you money.

You should love frames with turn ratios of six, and your average is likely two, says Rogerson. But watch out. “If your turn ratio is low, your inventory may be too low,” she cautions. Customers may perceive you don’t have anything for them and they may move on to other shops, which limits your optical’s potential.

7. Number of remakes. Your optical shop staff should be experts at preventing and troubleshooting prescription complaints to limit remakes, says Joy Gibb, an optical manager and consultant. You don’t shell out for the cost of remakes immediately, but if you have a high remake rate, you will most certainly pay more when it comes time to set terms with your lab, she warns.

8. Staff incentives. Skip spiff s, experts advise. Create an incentive system that encourages your optical staff to sell as a team and to suggest the products that truly benefi t your clients.

9. Technology that can protect or enhance your profi ts. We’re talking about much more than virtual try-in software here.

Some of your dispensary profi ts are walking out the door with shoplifters or with staff looking to make some extra money, especially if you carry designer frames. A basic camera surveillance system costs about $1500 per location and will save you thousands, says Johnson. Cameras can also protect your inventory from the employee who’s squirreling away 300 of your frames in her basement and selling them on eBay. (This is a true horror story I heard from an optical manager attending Vision Expo West.)

If you report and prosecute thefts, criminals looking to supply the black market will learn to avoid your practice.

Another good technological investment that helps you grab opportunities: a paging system that allows the optometrist to page the optician as the exam concludes for a smoother hand off . Johnson saw a $7,000-a-day uptick when he implemented a paging system at his seven-location practice, according to a recent article.

ECL OPTICAL SHOP

Raise Your Marketing Game with Demand ForecastingZIP CODE ANALYSIS BOOSTS DISPENSARY REVENUEYou and your staff know very well who your patients are and who buys from your optical dispensary. But do you know who your potential patients and clients are?

Zip code analysis gives your vision care practice the power to recognize fi nancial opportunities and respond to them proactively, explains Mark Johnson, Director of Optical Services at Virginia Eye Institute. It helps you identify the incomes, ages, buying characteristics, other demographic information of both the patients who frequent your practice as well as potential patients you don’t know yet.

To begin, use your POS software to pull the zip codes of the patients who’ve visited your practice within the last few years. Export your POS data into a spreadsheet that notes each patient’s zip code, as well as any other data you have in your POS, such as gender, age, and how much each patient has spent in your dispensary.

Study the POS data to discern clues to how your practice appeals to local markets. Where do most of your patients come from? How much does geographical proximity infl uence



Tip: You can get remake stats from your lab. Ask them about how your optical’s data compares to other opticals your lab serves.

EYES OPEN

Ophthalmology Practices: Here’s Why You Need an Optical DispensaryIf your ophthalmology practice has never brought on a dispensary, now is the perfect time to reevaluate your decision.

With insurance companies being what they are, it’s nice to have an out-of-pocket revenue stream that’s not dependent on insurance and is free from claims delays.

And, Medicare and private insurers are looking to reduce reimbursements for ophthalmic procedures. “They are not doing ICD-10 to help you make more money,” says Sharon Carter. “The reason they want you to be more specifi c is so that they can pay you less.”

Example: The decline in cataract surgery reimbursement will likely continue as CMS mulls moving less complicated surgeries from HOPDs and ASCs to in-offi ce surgical suites, observes Mark Johnson.

the mix? Do you discern patterns that suggest other factors besides geography are shaping your client base? Are there particular zip codes with higher percentages of dispensary purchases than others?

Next, go to a free zip code analysis site to learn more about the demographics of each zip code. Such sites will tell you:

• Population density, and how it compares to population densities in the county, state, and U.S.

• Median age, and how it compares to median age of county, state, and U.S.

• Median income, and how it compares to median income of county, state, and U.S.

• Household type―for example, single, married couple, etc.

• Average household size

• Housing type―for example, single unit, multi-unit rental, etc.

• Median home price

• Unemployment rate

Internet sites that off er free zip code data include:

• Esri: http://www.esri.com/data/esri_data/ziptapestry

• Sperling’s: http://www.bestplaces.net/

You can learn a ton from what these sites off er for free. Some sites also off er more detailed data for a price.

Once you’ve pulled together data for the zip codes in your area, use what you learn to fi nd out what kinds of clients your practice isn’t attracting. If you’d like to market to those patients, use the data you fi nd to brainstorm ways to appeal to them. For example, you might modify your frame inventory to appeal to a particular demographic where you see opportunity. Or, you might plan a pop-up event or trunk show that targets the demographic your practice is missing.

F A L L 2 0 1 5 7


THIS(Jay)walk

Some of the best practice management advice at Vision Expo West had me humming an old, raunchy Areosmith tune. Sometimes, you just gotta say “Jaywalk this way” and make your move in this risky business.

WAY8 E Y E C A R E L E A D E R S

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ADVICE FOR ENTREPRENEURS

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Imagine yourself on foot walking at a busy intersection during rush hour, Essilor's Howard Purcell told VEW attendees. There are two ways to make your way among vehicles that are much bigger and faster than you are. You can cross at the crosswalk, or you can jaywalk.

Brutal fact: It’s riskier for a pedestrian to cross at the crosswalk than it is to jaywalk. New York City stats cited in Slate tell us 50 jaywalkers a year are killed annually, but 200 pedestrians are killed at crosswalks.

The crosswalker assumes he’s in a controlled environment where everyone minds the right-of-way rules, and sometimes that assumption is deadly. The jaywalker knows that traffi c moves quickly and rules don't matter when you’re a small player. He keeps his eyes open and looks ahead.

ECPs absolutely must crosswalk when dealing with certain clinical and compliance issues. But when it comes to managing your business, consider jaywalking a little more. You're an entrepreneur: Look ahead and take some risks. “The best way to predict the future is to create it,” said both Honest Abe Lincoln and legendary management guru Peter Drucker―so look ahead of you.

Here's What's Coming,Eye Care LeadersEye Exams: “Over the past few years, I've had the chance to hang around with futurists,” Purcell said at Vision Expo West. And “in order to be a good futurist, you also must be a good historian.”

The Snellen chart is 150 years old, Purcell reminded attendees. It was designed to measure the visual acuity Victorians needed, not us, and it's history. We live in a world of glaring computers and zooming cars. "20/20 is no good anymore," he said, "20/8 is the best the human visual system can achieve."

Within fi ve to ten years, ECP’s will have ditched the Snellen charts. You'll be using Oculus-like technology to measure visual acuity.

Diagnosis: Looking for a consult in a decade, Sherlock? In ten years, you'll have your own version of Watson, an IBM supercomputer that blends artifi cial intelligence (AI) and analytical software.

Most of us recall Watson’s appearance on Jeopardy! a few years ago. Its spawn may be coming to your eye care practice soon.

Optical Dispensaries: 3D printing is a game changer, and it won't be just for custom lenses sold by fancy designers. It will be a way for you to fulfi ll orders faster and carry much more (virtual) inventory than you can aff ord to now.

Oh, and those ecommerce giants you thought were going to drive your optical shop out of business fi ve years ago? Turns out people like to shop in an actual, physical place and clients are craving omnichannel now. And guess what, ECP opticals, you've got a dog in this fi ght because you've kept your brick-and-mortar all along. Rock on.

Optical Retail: Are You Really the Underdog You Think You Are?You might assume your independent optical can't compete with retail giants like Luxottica, which counts LensCrafters, Sunglass Hut, and Target among its legions. After all, they’re Goliath’s and you’re just a little, local David.

You may just have an edge you don't realize you have, suggests Malcolm Gladwell, author of David and Goliath: Underdogs, Misfi ts, and the Art of Battling Giants, a 2013 book which many small businesses and entrepreneurs admire.

“I thought I understood [the story], and then I went back over it and I realized that I didn't understand it at all,” Gladwell has said in a TED talk available for free on TED’s site.

"So David, in that story, is supposed to be the underdog, right?" says Gladwell. He's a teenaged shepherd boy armed only with a sling and fi ve smooth stones, and Goliath is a hulking Philistine giant armed with cutting-edge tactical weapons for the time. He's got an entourage J-Lo would envy, and even an “attendant” to lead him onto the battlefi eld.

But the ancient people who originally heard this story would have understood that David’s unassuming looking sling can propel a stone 35 meters per second, and that the Valley of Elah stones David is using are twice the density of rocks elsewhere. David is highly accurate artillery.

In contrast, Goliath is “heavy infantry.” Certain textual clues have suggested to modern scholars that Goliath may well have had acromegaly―a pituitary tumor that causes overproduction of human growth hormone. “The pituitary tumor, as it grows, often starts to compress the visual nerves in your brain, with the result that people with acromegaly have either double vision or they are profoundly nearsighted,” Gladwell explains. So what looks to be Goliath's strength―gigantism―is related to his greatest weakness.

Lesson Learned: “Giants are not as strong and powerful as they seem,” Gladwell concludes, “And sometimes the shepherd boy has a sling in his pocket.”

THIS WAY(Jay)walk

all along. Rock on. powerful as they seem,” Gladwell concludes, “And sometimes the shepherd boy has a sling in his pocket.”

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WANNA

WIN LIKEWARBY?

IMPLEMENT THESE 6 STRATEGIES IN YOUR INDEPENDENT OPTICAL.


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If you’re an optical retailer, it’s hard not to feel threatened sometimes by Warby Parker’s eye-popping success. But there are many reasons to love Warby Parker, says David Friedfeld, owner of Clearvision Optical, a Hauppauge, NY family business that supplies independent opticals all over the world.

The fi rst reason is that Warby Parker has created a rising tide that lifts all boats. They’ve reminded their mostly millennial customers that eyeglasses are hip and fun―and that they’re even more fun if you have several pairs to switch out with diff erent looks. It’s highly likely those millennials are telling their parents and grandparents that glasses aren’t simply medical devices anymore―they are fashion too, Friedfeld told attendees at Vision Expo West.

An even neater thing about Warby Parker: nothing they do is dramatically new. TOMS’ One for One® has been around for almost ten years, Internet eyewear sales for twenty years, and aff ordable frames much longer than both. It’s just that Warby Parker has taken proven strategies from other markets, laser-focused them to succeed in their market, and added clever new twists that make money.

So let’s look at Warby Parker’s marketing strategies carefully and think about how to apply those relevant to you in your practice.

STRATEGY #1—WARBY PARKER IS GOOD, AND THE PEOPLE WHO WEAR THEIRGLASSES FEEL GOOD“Nice glasses,” Friedfeld told a server recently in a restaurant. “Thanks,” the server said proudly. “They’re Warby Parker. My girlfriend told me I had to get them because Warby Parker does a lot of good.”

“How many people know who makes their glasses?” Friedfeld asked Vision Expo West attendees. We all laughed. Warby Parker customers do.

Customers perceive that Warby Parker is good because of its Buy a Pair, Give a Pair® program. It isn’t just about free glasses for folks who can’t aff ord them, a public relations rep explained to me when I contacted her for this story. (My prolonged email exchange with her taught me that the company manages the press shrewdly and carefully.)

“Warby Parker partners with non-profi ts like VisionSpring to train men and women in local communities around the world to give basic eye exams and sell glasses in their communities at aff ordable prices … the teach a man to fi sh vs. giving him a fi sh method,” the PR rep explained.

[Full Disclosure: The PR rep sold me as a consumer. Warby Parker is good and I wanted to be a part of all that goodness. I promptly started my Home Try-On selections. I have Holcomb, Upton, and June in my virtual box and have two more to go. I was able to select these models with confi dence because the opticians I met at Vision Expo West told me my face is heart-shaped, and actually not the square I thought it was for 40-plus years. But I digress.]

Lots of vision care practices do good things, Friedfeld pointed out. You do things like overseas mission work or collecting frames for the Lion’s Club. The big diff erence between you and Warby Parker? You don’t talk about the good you do if you’re a Baby Boomer or Gen-X’er because your mama told you it’s rude. It’s not rude in 2015. It’s good. And it’s strategic. Publicize the good you do on your web page, your social media channels, and in conversations with your clients.

Abbot Kinney, L.A.

This façade is as playfully artistic as its Venice, California location. The octagonal library tables are arranged in an informal cluster.

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WANNA

Strategy #2—Warby Parker doeS Social media very WellYou may not have the bandwidth to tweet, pin, and post about your practice multiple times a day, but you can certainly post on a social media channel a couple times a week. Take pictures of fun frames you’re carrying, your friendly staff, or your trip to Guatemala to do eye exams. (See #1). See pages 32-35 for other social media tips your eye care practice can try.

Strategy #3—Warby Parker createS intereSting eventS and SPurS you to think about eyeglaSSeS at timeS you normally don’tThe Class Trip is an old yellow school bus outfitted with an optical shop. It’s

currently parked at The Picnic at Barton Springs—a food truck trailer park in Austin, TX. You can try on frames after dining at establishments like Ms. P’s Electric Cook, Turf n’ Surf Po Boy, and Hey! You Gonna Eat or What? It’s a hipster happening indeed.

This past August, Warby Parker teamed up with Pop-In@Nordstrom to offer “a curated selection of frames … as well as specialty items with a literary slant” in pop-up locations at six department stores.

Mobile opticals are nothing new, though they they’re typically break-even the first one or two years for most ECPs, says Friedfeld. The pop-up concept doesn’t require as much investment. You might set up in a high-end boutique or jewelry store on a Saturday if you sell high-end frames, or at community fairs for lower-priced frames.

Several Vision Expo West speakers mentioned that the trunk shows independent opticals used to do in the late 80s and early 90s are back and more successful than ever. Some practices report bringing in $50,000 at a trunk show, says consultant Sherrie Rogerson.

The key to making money, says Friedfeld, is to come up with an optical retail event that generates excitement in your market or pops up in a space where lots of potential customers hang out.

Strategy #4—Warby Parker carrieS a limited Selection of frameS, creating a ShoPPing exPerience that feelS SimPle and tranSParentShowrooms feel curated, not overwhelming. You can create a

WIN LIKEWARBY?

Atlanta, GA


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You don’t talk about the good you do if you’re a Baby Boomer or Gen-X’er because your mama told you it’s rude.

It’s not rude in 2015. It’s good. And it’s strategic.

curated vibe in your optical as well. Limit the number of frames you offer, and cut out frames that don’t turn well. Think about how you can make your shop simple and easy to navigate.

SUBHED: StratEgy #5—Warby Parker’s brick-and-mortar StorES cElEBratE their locationsThe first Warby Parker store Fieldfeld ever saw was in New York City’s meatpacking district. The build isn’t fancy, and has a rough-hewn, old-timey warehouse décor that seems perfectly situated in this location.

Its Hollywood store is in The Standard, a mid-century modern hotel. The place seems so cool you feel like you might spot Don Draper playing hooky from SDCP, having accomplished one of his

mysterious escapes from New York.If you’re sprucing up your décor,

consider incorporating design elements that connect your optical to your community. For example, one independent Colorado optical group hired a professional printer to print a photograph of nearby mountain scenery—the perfect wall mural for the space, says Bill Gerber, a consultant with Optical Marketing Group who spoke at Vision Expo West.

StratEgy #6—WarBy ParkEr’S SHoWroomS arE ExamPlES of gooD oPtical shoP design.They are well lit, uncluttered, and signed well. And while some seem very spacious, many don’t take up much square footage at all. The New Orleans

store, for example, is a small jewel tucked away downtown by the river.

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Let’s Review...

The Warby ParkerSuccess StoryThe optical shop playing field has changed dramatically in the past five years, all because a biz school graduate lost a pair of $700 glasses while hiking in Tibet.

“The technology behind a pair of glasses is 800 years old,” co-founder Dave Gilboa has mentioned to various media outlets over the years. “It’s kind of crazy you can buy a new iPhone for less than it costs to buy a pair of glasses,” he told USA Today late last year.

A typical pair is $95, though you can get the Colonel monocle for $50. Most business is online, thanks to a Home Try-On program that did for frames what Zappos had done for shoes several years earlier.

The company reached its first annual sales goal within three weeks of launching its website, reports the Hubspot marketing blog. Significantly, the founders spent a full year and a half before that “creating the band, product, strategy, and values that would eventually become Warby Parker.”

Warby Parker opened its optical retail stores in 2013 and added several experiential brick-and-mortar stores last year. There are about 10 nationwide with plans to get to 20 by year’s end as the company moves from ecommerce to omnichannel. “The stores sell an average of $3,000 a square foot annually, higher than most retailers not named Apple Inc.,” quips The Wall Street Journal.

Warby Parker is privately held, so it doesn’t disclose revenue. But there are some clues. By June 2014, the company’s Buy a Pair, Give a Pair program had donated one million pairs of glasses total. In July 2013, 500,000 pairs had been donated, an uptick that signals the company’s rapid growth. Warby Parker is worth about $1.2 billion right now, experts estimate.

Last year, Warby Parker forged into the 50 percent of the prescription eyewear market they’d been missing—offering progressive lenses in the $300-$350 price range that undercut competitor prices and took one more edge away from optical dispensaries.

With the competition heating up and taking clever marketing up to eleven, it’s more crucial than ever to make sure your optical dispensary is well-managed, that you adopt smart marketing strategies that work for your customer base, and that you closely monitor clear profitability benchmarks.

Greene Street, NYC

wANNA WIN LIKEWARBY?


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Hayes Street, San Francisco

Greene Street, NYC

Greene Street, NYC

Atlanta, GAGreene Street: Warby Parker’s “flagship retail store” in SoHo’s historic Cast Iron District. Terrazzo floors, library ladders, vintage books, and gleaming brass lamps are library-like. Backlit shelves and jewelry-store quality lighting draw attention to the frames. Simple signage calls out affordability.

The San Francisco store’s façade pays homage to local landmarks like the Transamerica Pyramid, Lombard Street, and Golden Gate Bridge. Do you think that lady cruising down the hill while reading is going to have a problem?

The Atlanta showroom riffs on the familiar library theme. This time, tufted leather couches and parquet floors evoke a gracious, Southern reading room that celebrates tradition. The lighted “Reference Desk” sign creates a strong focal point.

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Warby.indd 17 9/29/15 5:25 PM

What the 2016 Medicare Physician Fee Schedule has in store for youThis year’s Medicare Physician Fee Schedule is 798 pages of proposed reimbursement and regulatory changes, some of which that will impact your eye care practice’s bottom line in 2016.

We’re going to spare you the mind-numbing detail and cut to the chase. Here’s what you should be looking out for. Expect the fi nal rule by November 1, 2016.

Ophthalmic reimbursement will stay fl at amidst a 0.5% overall Medicare reimbursement increase in the fi rst MPFS after SGR repeal.

It could be worse: Gastroenterology will take a 5% hit in this fi rst fee schedule after SGR repeal and radiation oncology will take a 3% cut.

It could be better: Pathology gets an 8% hike.

You’ll see 1% reimbursement increases for codes like these:

• 66821, After cataract laser surgery

• 67210, Treatment of retinal lesion

• 92012, Eye exam, established patient (facility)

• 92014, Eye exam and treatment, established patient, 1 or more visits (non-facility)

And 1% decreases for codes like this:

• 66984, Cataract surgery with IOL insert, stage 1 (facility)

And no change at all for codes like these:

• 92012, Eye exam, established patient (non-facility)

• 92014, Eye exam and treatment, established patient, 1 or more visits (facility)

“Misvalued Codes”: The ACA requires CMS to review and reduce the reimbursement for “misvalued codes.” Here are the codes up for reimbursement cuts in the fi nal rule:

• 92002, Eye exam, new patient• 92136, Ophthalmic biometry• 92240, Icg angiography• 92250, Eye exam with photos• 92275, Electroretinography

ECL Washington Watch

If you participate in PQRS to avoid Medicare payment cuts, CMS is proposing new diabetic retinopathy measures, as well as 2 new Stark exceptions (see p. 43 of this issue).

The proposed MPFS for 2016 also fl oats the idea of in-offi ce cataract surgeries and reimbursement cuts to go along with the site change.

For updates and analysis of the fi nal 2016 MPFS, go to www.eyecareleaders2020.com after the November 1, 2015 publication date.

EYES OPEN

Eye exam and treatment, established patient, 1 or more

The ACA requires CMS to review and reduce the

It could be worse: Gastroenterology will take a 5% hit in this fi rst fee schedule after

SGR repeal and radiation oncology will take a 3% cut.


Washington Watch_NEW.indd 18 9/29/15 5:26 PM

Former CMS Chief Now Leads Insurance LobbyMarilyn Tavenner has taken the helm at AHIP, a powerful private insurance lobby that includes Aetna, Anthem, Humana, Kaiser Permanente, many Blues, and other smaller companies. Tavenner replaced Karen Ignagni, who led AHIP for 22 years.

As CMS Administrator from late 2011 until January 2015, Tavenner oversaw the $800 billion annual budget for federal health programs. She is perhaps best remembered for the rocky rollout and eventual repair of Healthcare.gov. Tavenner brings with her to AHIP her former chief of staff at CMS, Aryana Khalid, Politico reports.

Tavenner’s move to AHIP raises eyebrows among providers and patient advocates who feel the relationship between federal regulators and the health insurance industry is too cozy to do most of us any good.

Federal confl ict-of-interest rules prevents Tavenner from lobbying her former HHS colleagues directly during the Obama administration’s twilight. She has been able to lobby Congress directly since her fi rst day on the job.

Some Washington insiders airily dismiss confl ict-of-interest restrictions as technicalities. Nothing prevents Tavenner from sending other lobbyists to CMS on her behalf.

“There are minions that have low-heeled shoes that go do that part ... K Street is full of those people,” Meredith McGehee, policy director for the Campaign Legal Center, told Politico.

In addition to her reported entourage of low-heeled minions, Tavenner will no doubt get a nice pay raise, predicts Modern Healthcare. As CMS administrator, she earned $165,300 a year. Karen Ignagni earned $2 million as AHIP’s CEO in 2013.

Tavenner (left) with former HHS Secretary Kathleen Sebelius in 2013.

Meet Your New ICD-10 OmbudsmanOohrah. Looks like CMS has hauled in the big guns to handle your ICD-10 payment issues.

Dr. William Rogers is your new ICD-10 ombudsman. CMS has opened a communication offi ce to monitor and resolve implementation issues. As ombudsman, Dr. Rogers will “triage” physician issues.

Dr. Rogers has served as Battalion Surgeon in the USMC Reserves. (The unoffi cial marine motto is “Improvise, adapt, and overcome,” which seems fi tting in this particular context.)

He has served as Director of the Physicians Regulatory Issues team at CMS since 2003, and is Clinical Assistant Professor of Emergency Medicine at Georgetown University.

Dr. Rogers is a regular on CMS provider calls and is always helpful with coding questions, comments Torrey Kim of Part B Insider.

His new contact info at CMS will be: [email protected].

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TAKE THELONG

Analysts can sound bleak about your eye care practice’s future as they warn us all about looming profi t cuts and rising business expenses. But facing the brutal facts today helps you plan for a profi table tomorrow. Here’s what you can expect on the road ahead.

WHAT YOU NEED TO KNOW TODAY TO FORGE YOUR PRACTICE’S FINANCIAL FUTURE

VIEW

by Kara Hiltz


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TAKE THE LONGVIEW

1. Obamacare presents fi nancial hazards—and opportunities. Forty-nine percent of eye care professionals say healthcare reform is their biggest fi nancial concern, according to the most recent market survey published by Eyecare Business.

So far, ACA has been a mixed bag for vision care. While 61 percent of eye care professionals have reported a decrease in profi t margins, there are opportunities. For instance, many medical plans now cover wellness eye exams for children. These services don’t produce large profi ts, but they do bring in new patients, which can make all the diff erence.

2. Profi ts will begin to drop at two to four times the current rate, predicts Dan D. Chambers, MBA, COE, chief administrative offi cer at the Key-Whitman Eye Center in Dallas, TX. “In a traditional ophthalmology practice with an average overhead, a 10% reduction in collected revenue will require a nearly 30% increase in patient volume to sustain a physician’s present income,” Chambers estimates.

Labor and benefi ts will likely take the biggest bite out of your vision care practice’s profi ts, says Chambers. To off er competitive benefi ts to your staff , some of which are now mandated, many practices will need to focus on practice management and on bringing new patients in the door.

3. The old days of doctors ignoring the business side of their practices are gone. Yes, you need to hire smart back offi ce staff to handle marketing, billing, and other revenue boosts, but you also need to stay involved yourself. “Put no fewer than eight hours per week into co-managing the practice with lay management staff ,” advises ophthalmic practice management consultant John Pinto.

4. More practices will turn to OD-MD comanagement as a survival strategy. “The ratio of ODs to MDs will grow from one-to-one ratios to two-, three-, and four-to-one ratios,” Pinto predicts. “By 2024, group ophthalmology practices without material optometric staffi ng will be rare,” he writes in an Ocular Surgery News article.

5. We will see more non-physician practitioners in vision care. “To optimize clinical staff to the highest levels, practices will likely hire more Nurse Practitioners and Physician Assistants, Chambers says.

6. Practices continue to take the slow ride to technological change. Like the most diehard Foghat fans, vision care practices take it easy when it comes to some kinds of technology.

While 75 percent of ophthalmology practices have EHR, only 50 percent of optometry practices do.

And while social media can be a powerful marketing tool, regulatory concerns prevent many practices from racing full speed ahead. Nearly half of surveyed eye care practices have a Facebook or Twitter account, according to Eyecare Business. But only 30 percent of those practices post at least once a week on social media, with most practices posting much less frequently. It remains to be seen whether social media becomes a dead end road for marketing.

7. You may have to merge with another health care organization just to be able to aff ord your clinical equipment. Larger practices can justify the cost of cutting-edge eye care and surgery equipment because it brings in higher volumes of patients, but “smaller practices simply won’t be able to aff ord new technology” with fewer patients using the services, warns Chambers. Consolidation will be one way to pay for climbing technology costs.

8. Your practice manager will need to be a geek. To make a practice profi t today, offi ce managers need to master HIT, data mining, fi nancial benchmarking, health care policy, and more. If you have a great practice manager who is weak in one of these areas, get her training or hire support staff or consultants with these competencies.

9. An upswell of powerful demographic shifts will work in your favor. More and more Baby Boomers are carrying AARP cards. Today, the over-65 crowd makes up 13 percent of the population. By 2030, that number will swell to 20 percent.

Bonus: Seniors have the lowest poverty rate of any age group. And they’ll be spending some of that money on eye care co-pays. Seniors consume as much as 10 times the amount of eye care services as younger patients, Pinto observes.

10. There will be fewer of you to handle all those new patients. You won’t have to hustle for referrals quite as much as you do now. The number of ophthalmologists in training is dropping.

The U.S. population has grown by 11 percent over the past decade but the number of residency slots for ophthalmologists has decreased by about 11 percent, according to Pinto.

11. Plan early for your retirement. Start looking for a successor yesterday. The bad news about the expected decline in trained ophthalmologists: it will be harder to sell your practice when it’s time to retire. But there’s a solution if you plan ahead, says Pinto.

Instead of fi nding new ophthalmologists to buy out practices, more ophthalmologists will take on new graduates as associates and remain owners, Pinto predicts. It’s a win-win: Even in retirement, you’ll enjoy a passive income.

Trim Size : 8 .1" x 10.75"



Trim Size : 8 .1" x 10.75"

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HOW TO GETWHAT YOU WANT

FROM

The big payers are looking to bulk up even more. You can hold your own in contract negotiations with any payer―from fl yweight to super heavyweight―if you know the ropes.

What's the most important fi rst step toward a win-win agreement that satisfi es both you and the payer? Involve multiple eye care practice staff ers in a contract review.

Some doctors don’t realize what a diff erence a sharp biller or coder can make, says Melody Irvine. Folks in your back offi ce have no doubt spotted the ‘usual suspects’ already, and they’re more familiar than you might be with sneaky payer tricks.

Want another tip to stay strong? Keep copies of all your yearly contracts in one place where all your staff can fi nd them.

If you’re currently contracted with the payer and considering contract renewal, compare language year over year before signing again, Irvine suggests. Some payers try to slip in new terms at renewal that are unfavorable to you, hoping you and your offi ce staff won’t notice.

PAYERS


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Discover 13 contract questions that protect your profits✔How good is the payer’s online

access? Is the payer’s site user-friendly? Does the payer promptly update beneficiary and claim information so that your back office can easily look up insurance verifications?

✔Is the payer accredited by the NCQA? The National Committee for

Quality Assurance is an independent organization that reviews insurance companies to make sure they're fi nancially sound, explains Irvine.

✔Are clinician responsibilities reasonable? Will the medical

record requirements turn you into a documentation drudge? What’s your responsibility for phone calls, hospital visits, or ED visits?

✔How hard is it to onboard new physicians or NPPs

with the plan? Make sure the plan’s credentialing process isn’t so sluggish that you’re stuck waiting around to monetize a new hire’s services.

✔What are the deadlines for contract renewal? Make sure there’s no

evergreen clause that automatically renews the contract, Irvine warns. You want the ability to re-negotiate every year.

✔Does the contract have a most favored nation clause, and if so, are

you okay with that? An MFN clause requires you to give that plan the lowest rate you’ve negotiated with any other plan.

✔Does the contract have a silent PPO clause? If so, you should eliminate it,

Irvine says. Silent PPOs have been around for a long time, but they can catch practices unaware, she warns.

✔What’s the policy for retroactive denials? Prohibit the plan from

rescinding money if the claim is more than 120 days old, Irvine suggests.

✔What are the off set and withholds provisions? These terms give the

plan the s.

✔Does the contract defi ne ‘clean claim’ clearly? Should you add a provision

that the insurer apply interest to denials of clean claims when the payments come in too slowly?

✔Does the contract have a binding clause that prevents you from fi ling

a lawsuit in the event of a dispute? If so, Irvine suggests you negotiate to remove it.

✔Will the plan notify you in writing 30 days in advance of any policy change?

That’s a good clause for you to have.

✔Can you write a 90-day out clause into the contract? If you fi nd your practice

losing money once you’re under the contract, the 90 day out clause allows you to cancel the contract before the contract is out, even without cause, says Irvine.

Profit PUNCH-In: The Angel In Your Corner

• Check the payer’s defi nitions for other revenue-crucial terms like “timely fi ling” and “medical necessity.” These defi nitions may be in the policy manual, not the contract.

• Some payers may try to get by with an abridged schedule containing, say, the 10 most commonly billed codes for your specialty. Don’t settle for that nonsense. Ask for the complete schedule.

• The contract might slip in modifi er policies involving -25, -51, and -59 that could slash your reimbursement. If an expert coder or biller reviews the contract, she will spot this kind of trick and alert you to potential cash fl ow challenges.

• Your review team should scrutinize the most recent policy manual before signing an agreement. The manual often reveals much more than the contract about revenue-crucial policies for credentialing, claims submission, coding policies, appeals, and grievance procedures, Irvine says.

EYES OPEN

PAYERSHOW TO GET WHAT YOU WANT FROM



Avoid these 7 revenue-busting negotiation mistakesThe bigger and shrewder the payers become, the savvier you need to be. Are you making the all-too-common mistakes as you grapple with a payer during a negotiation?Such mistakes will hamstring your profi ts once you’re locked into a contract, says billing and practice management consultant Steve Verno.

MISTAKE 1. RUSHINGThe negotiation process for a fi rst-time contract with a payer can take up to a year. Set a “you need us” timeline so that you don’t feel bullied by the payer’s negotiation tactics.

MISTAKE 2. ACCEPTING A BOILERPLATE CONTRACT“A standard or boilerplate contract is usually one sided, and it favors the insurance company,” Verno warns. Always bargain for specifi c points that benefi t your eye care practice.

MISTAKE 3. SETTLING FOR “REASONABLE” AS A DEADLINE FOR CLAIMS SUBMISSIONS, PAYMENTS, AND APPEALSVerno has seen payer contracts that say they will pay claims in a “reasonable” time frame. You can bet you and your payer will disagree with what “reasonable” is unless you spell out each time frame in business days.

MISTAKE 4. ACCEPTING A GENERIC FEE SCHEDULE ATTACHMENTMake sure the payer’s fee schedule contains reimbursement amounts for the codes your eye care practice reports most often.

MISTAKE 5. EVALUATING THE PAYER’S PROPOSED REIMBURSEMENT AMOUNTS IN ISOLATIONMake sure your practice manager or biller keeps a grid listing the reimbursement amounts each insurer pays for your most commonly billed codes.

MISTAKE 6. FOCUS SOLELY ON REIMBURSEMENT RATEBe sure to check the payer’s policies on modifi er use, multiple surgery adjustments, bundling, and other policies that will aff ect pay up.

MISTAKE 7. OVERLOOKING PRE-AUTHORIZATION AND PRE-CERTIFICATION REQUIREMENTThe contract should spell out pre-auths. If the payer says they’re “in the provider manual,” make sure you check the manual before signing.

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Your front desk is the fi rst spin of your revenue cycle, say RCM experts. So are you sure your front desk staff ers are collecting the correct co-pays from each patient?

Chances are, they aren’t. In a recent study of all providers, 42 percent said they didn’t verify patient co-pay responsibility during the visit.

With higher deductibles and co-pays becoming the norm, more of your revenue than ever before is coming out of pocket. Failing to collect co-pays up front puts your RCM on the road to a series of invoices, some of which you’ll have to send to collections or write off as bad debt.

Collect more co-pays at your front desk with these tips from billing expert Barbara Cobuzzi:

1. Train your front desk staff to verify insurance eligibility and co-payment amount when the patient makes the appointment. Make clear that patients need to pay co-pays when they check in at the appointment.

2. Ban this question: “So nothing’s changed since you saw us last?” If the patient is feeling sick, tired, hurried or forgetful, chances are she’ll say “Yes, it’s all the same.” It’s probably not.

Better for the front desk staff er to ask, “May I see your insurance card to make sure we have the correct information” or “You still live at 101 Oak Lane and the best number to reach you is still 555-555-555?” Front desk staff ers who ask these questions with a friendly, effi cient tone actually make patients feel like the practice is taking good care of them.

3. Check the insurance card every time to make sure it’s current and you have the correct co-pay information. The patient may have the same insurance as he did at the last visit to your practice, but the co-pay may have changed.

Collect co-pays at check-in. If you collect at check out, it’s easier for patients to slip out with no one noticing.

4. Make it as easy as possible for patients to pay. Accept credit and debit cards, checks, or cash.

5. Train your front-desk staff to handle a patient who balks at paying the co-pay “because she has insurance.” While terms like “deductible” and “co-pay” may seem obvious, only a small fraction of your patients truly understand most insurance jargon, estimates a recent Journal of Health Economics study. Your front desk staff should know how to explain the basics―that the insurance company requires your practice to collect the co-payment at the time of the visit.

ECL REVENUE BOOST

Front desk and patient statement strategies that pay

Tip: Make sure your front desk staff ers know the location of a nearby cash machine, Cobuzzi recommends. That way, if the patient claims to not have any cash, the friendly front desk staff er can tell him where the nearest ATM is and not to worry, she’ll hold his place open while he goes and gets the cash.

EYES OPEN

ECL REVENUE BOOST


Revenue Boost.indd 28 9/29/15 5:30 PM

Spot and Stop This $180 Strabismus Surgery Reimbursement MistakeIS YOUR PRACTICE BILLING 67312 WHEN YOU SHOULD CHOOSE 67311?

If you perform a strabismus surgery, where you resect the lateral rectus muscles of both the patient’s eyes, chances are you’re getting shortchanged.

Why: Your coder may wrongly believe that 67312 (Strabismus surgery, recession or resection procedure; 2 horizontal muscles) is correct because she’s focusing on the “2 horizontal muscles” in the CPT® descriptor and missing that the surgery involved both eyes, explains ophthalmology coding expert Maggie Mac.

But the strabismus surgery CPT® codes (67311-67318) describe unilateral procedures―procedures performed on one eye only.

The correct choice is 67311 (Strabismus surgery, recession or resection procedure; 1 horizontal muscle) bilaterally. When you work on the lateral rectus muscles of both eyes, your coder should report 67311-50 or two instances of 67311 on two lines―for example, 67311-LT for the left eye and 67311-RT-51 (Multiple procedures) for the right. Medicare will base payment on 150 percent of the fee schedule amount for a single code.

So if your coder incorrectly reports 67312 when she should be using 67311 bilaterally, you’re losing about $180 reimbursement for the procedure.

Medicare multiplies 67311’s relative value units (16.92 RVUs) by the conversion factor to get about $600. Appending modifi er 50 for the bilateral procedure means that Medicare would reimburse you 150 percent of that, giving you about $900 (give or take, depending on where you practice).

With no bilateral pay adjustment, the RVUs for 67312 would only bring in about $720, substantially less than what your practice could have if it was coded correctly.

F A L L 2 0 1 5 29


Let’s put aside for a moment all the things your front desk can do to collect more revenue up front and focus on a single piece of paper that’s probably bottlenecking your RCM: your patient billing statement.

True Confession: I’ve been working in or writing about health care for a total of 20 years. And yet few things confuse me more than the health care bills I receive at my house. I must study the statements long and hard to decipher how much I owe. Many times the billing statements I receive are so ambiguous I’m not even sure if any action is required from me.

Step back and take a look at the patient billing statements your practice or your billing company sends. Could your mother understand it if she received it? What about your dimmest neighbor? Can you?

Here are 7 things you can do to clarify your patient billing statements, recommended by HFMA:

1. State clearly that it’s a bill so that your patients don’t confuse it with an EOB or any other of the non-

actionable “statements” they routinely receive from health care entities. Use phrases like “Bill for Eye Care Services for your 11/16/2015 visit.” Use arrow graphics with phrases like “Please pay this amount.”

2. Briefl y describe the services being billed. Avoid jargon. Clarify what insurance is expected to pay. The bill should list the patient’s primary and secondary insurance, as well the amount pending from insurance.

3. Show clearly what the patient is expected to pay. Label the amount “due from patient.”

4. Supplement the itemized, “business part” of the statement with clear directions in plain English. HFMA suggests:

Thank you for using [insert your Eye Care Group here]. Your satisfaction is our primary concern. We have billed your insurance company; however, there is a remaining amount, as shown. Please send the amount shown to the address above. Again, thank you for visiting us.

5. Let your patients know how they can ask questions about their bills. In addition to the address where they should send payment, include a phone number. Supply the offi ce hours when someone will be answering the phone.

6. And most importantly for patients experiencing vision problems (and everyone else too), make your statement easy to read. Here are a few print readability tips from some good graphic designers I know:

• Use a plain white background.• Use a clean layout. White space is

easy on the eyes.• Use as large a font as you can.• Choose a sans serif font like Ariel.• Avoid italics.• Watch the leading (space between

lines of text) and tracking (space between letters). If they’re too tight, your statement will be diffi cult to read.

• Use ragged right margins. If you choose justifi ed right margins, the resulting spaces between words will make the text in your statement hard to read.

Secrets to Patient Billing Statements That Pay UpWHAT MOST VISION CARE PRACTICES GET WRONG

ECL REVENUE BOOST



ECL Marketing Magic

How to Diagnose and Treat Your Online Reviewsby www.practicebuilders.comby www.practicebuilders.com

Who cares about online reviews? They are Who cares about online reviews? They are just words posted on websites that just few just words posted on websites that just few people read, right? Wrong! Online reviews people read, right? Wrong! Online reviews of your vision care practice directly aff ect of your vision care practice directly aff ect the number of new patients you will see, and the number of new patients you will see, and even whether current patients will stay.even whether current patients will stay.

In just a few short years, casual remarks on social media In just a few short years, casual remarks on social media sites like Facebook have joined the “word-of-mouth” sites like Facebook have joined the “word-of-mouth” referrals we’re all so familiar with. But digital word-of-mouth referrals we’re all so familiar with. But digital word-of-mouth is amplifi ed and more permanent than verbal conversations, is amplifi ed and more permanent than verbal conversations, potentially reaching people far beyond an individual’s immediate potentially reaching people far beyond an individual’s immediate friends and acquaintances.friends and acquaintances.

Take Control of Your Practice’s Web PresenceMore and more patients look up doctor or practice names on the web before making the fi rst visit―even if they’ve been referred by friends. If you have good SEO (search engine optimization), your website will appear, but the review websites will also appear.

The good news is that you have full control over your own website’s design and functionalities. Take these steps:

• Make sure your website includes best practices and refl ects your brand and identity.

• Set up “basic” social media accounts such as Facebook, Twitter and LinkedIn because they too, will appear in search results for your name or your practice’s name. The advantage of being proactive: You fully control these platforms. You can be notifi ed as soon as any comment s are posted and you will also be able to delete any wall posts on your Facebook page.

• Be strategic. Use best practices to set up and maintain your social media accounts. Best practices include branding that represents your practice, creating geo-targeted followers on Twitter, and incentivizing visitors to “like” and “share” your Facebook page, etc.

• Monitor review platforms such as Yelp, Healthgrades, and RateMDs for any new activity on your profi le. (It ‘s wrong to assume that you don’t have a profi le if you haven’t created it yourself because patients and even the web sites can create profi les for you.)

A Seismic Power ShiftOnline reviews are shifting the power balance from the practice to the patient. Consider these factors:

• Patient reviews can be inaccurate and unfair.

• The same comment can appear on multiple social media and review websites that are diffi cult to monitor.

• Patients can review physicians any time after their visit (one day after or one year after).

• Newly posted reviews may be read by many people long before the physician ever knows about them (assuming the physician even has a process to daily monitoring).

• Physicians and their staff s are busy. It’s diffi cult to respond to reviews―negative or positive.

• Most practices lack a strategy for eff ectively dealing with reviews.


Marketing Magic.indd 32 9/29/15 5:31 PM

Hurray! The Review is Positive

• If the reviewer is anonymous, post a thank you on the review site. For a reviewer who identifi es herself, it’s good public relations to contact her, thank her for the kind words, and ask for a referral.

• During the “thank-you call,” ask permission to use the patient’s review as a testimonial in your marketing eff orts. The testimonial can be a great addition to your print advertising as well as your website content.

• Invite a video testimonial: If you plan to enhance your website with a video or add video to your YouTube channel, this is a great opportunity to ask the patient if she might be interested in doing a video testimonial.

• Focus on the positive: Focus on what made the patient happy (e.g. diagnosis, waiting time, staff , bedside manner, etc.). Consider incentivizing those at your practice who helped create that positive experience.

Rx for Negative ReviewsIf the negative review is accurate:

• Read the review more than once, analyze it without getting emotional and consider what went wrong with that specifi c patient. Answer these questions: Does this happen all the time? Why did it happen? How can I fi x it? This is the time to learn from mistakes.

• Contact the patient (if not anonymous). Ask if there’s any way to make it right for him. If he then turns into a happy patient, you can request that they delete the negative review.

• Private message (if anonymous): Many review websites have the functionality to send a private message to the reviewer. If the reviewer is anonymous, it’s best to send a private message, explain the situation, and promise that you’ll make it right. Ask the reviewer to contact you.

• Comment on the review: If you can’t reach the patient (or was anonymous and didn’t respond), take the high road, accept any fault, and explain the situation along with steps that have been taken to improve the situation. Do not get into any discussions or arguments with the patient. It will not refl ect well on you and it will be open for everyone to read. Also, do not get into the specifi cs of your patient’s condition. You should always have HIPAA compliance in mind when commenting on a review.

• Appreciate the knowledge: You’re always better off knowing. Now you know what might not be working well in your practice so you have the opportunity to fi x it, get happier patients, and garner more referrals.

• Gain more positive reviews: Based on what you have learned from the negative review, concentrate your time and energy to receive more positive reviews from your happy patients (you should always have a process to ask for reviews from satisfi ed patients). Receiving more positive reviews will average out and bury your negative reviews.

diagnosis, waiting time, staff , bedside manner, etc.). Consider incentivizing those at your practice who helped create that positive experience.

get into the specifi cs of your patient’s condition. You should always have HIPAA compliance in mind when

You’re always better off knowing. Now you

Gain more positive reviews: Based on what you have learned from the negative review, concentrate your time and energy to receive more positive reviews from your happy patients (you should always have a process to ask for reviews from satisfi ed patients). Receiving more positive reviews will average out and bury your negative reviews.

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ECL MARKETING MAGIC

If the negative review is incorrect and inaccurate:

• Think again. Is the review really incorrect and unjust? It’s usually diffi cult to hear and accept negative comments, especially if we’re not used to hearing feedback directly from patients and through such platforms.

• Contact the patient (if not anonymous). Find out what has bothered him. Maybe it was a miscommunication or a misunderstanding that you can resolve. Explain your side of the story and politely ask the patient to remove the post.

• Private message if anonymous and explain.

• “Flag”: Some review websites give you the ability to fl ag a review as inappropriate or inaccurate. In doing so, you should explain in detail why you think the review is inaccurate and should be removed. Some review websites remove poor reviews based on sound reasoning.

• Comment on the review and explain your side of the story: Be respectful. Your comment will be open for everyone to see. You don’t want to taint your image by being argumentative and

unappreciative of patient feedback. You should always have HIPAA compliance in mind when commenting on a review.

• Take legal action: If none of the above tactics work, you can take legal action to make sure the review is removed. There are some companies who can represent you, but it will likely be time-consuming and expensive. It is much easier to resolve a negative review through the above-mentioned steps.

• Gain more positive reviews (as explained on the previous page).

Knowledge Is PowerYou have the opportunity to know more about your practice today than you ever did before. Just remember that your patients will have the same knowledge. Change that downside to an upside! Let the brave new world of social media help you improve your practice’s operations and patient satisfaction.

And don’t settle for “no reviews, so I’m good.” New patients search for ophthalmologists and vision care providers with great reviews, not the ones with bad reviews or no reviews.

For more information:Practice Builders, LLC1 Technology Drive, Building I, Suite 829, Irvine, CA 92618800.679.1200 | [email protected] | www.practicebuilders.com



HIPAA Help for Social Media TestimonialsCheck out the following form authorizing social media testimonials created by said Paul Hales, Esq., a healthcare attorney in St. Louis, MO. Hales includes this template in his HIPAA E-Tool:

Dr. Smith

Authorization for Testimonials - Social Media

Date:

Name of Patient:

Date of Birth:

Last 4 numbers of SSN: XXX-XX-

Address:

We very much appreciate the fact that you are pleased with your experience at Dr. Smith and Associates and wish to provide a testimonial

expressing satisfaction with your experience. Your testimonial may be posted on our website, used in social media or printed materials

and may be released to the media. Please understand that a testimonial may involve the use or disclosure of information that is protected

by health privacy law. In order for you to make a testimonial you must authorize the use or disclosure of information about you in your

testimonial. You may use this form to provide the necessary authorization.

Authorization:

I hereby authorize the use and disclosure of information I describe in this form for testimonial purposes by Dr. Smith. My authorization to use my

information extends to any persons and agents working on behalf of Dr. Smith to create or maintain materials in any format that may include my

testimonial including but not limited to printed materials, websites, and social media.

1. Description of the information to be used or disclosed in my testimonial:

Please describe the information that will be in your testimonial―for example, your name, picture, a video of you talking about your experience,

etc.―in this box:

2. Name or Identifi cation of persons to whom I authorize Dr. Smith to make the requested use or disclosure:

I authorize Dr. Smith to use my information as a testimonial for disclosure to the general public who may view or read my testimonial on

materials created by or for Dr. Smith and Associates including but not limited to printed materials, websites, and social media.

3. Purpose

The purpose of the requested use or disclosure is “At My Request.”

4. Expiration Date of this Authorization

This authorization shall be valid―unless I revoke it earlier in writing―for ten (10) years from the date I sign it. I understand that:

1. I may revoke this authorization at any time in writing and that Dr. Smith will furnish me with a form to make my written revocation if I ask

for the form but I am not required to use that form to make my written request for revocation.

2. My revocation will not apply to the information that has already been released as permitted by this authorization.

3. Dr. Smith may not condition my treatment or payment, enrollment or eligibility for benefi ts on whether I sign this authorization.

4. The persons to whom this information is disclosed may re-disclose the information and it will no longer be protected by federal health

information privacy law.

5. I have a right to request and receive a copy of this authorization.

I have read and understand this Authorization for Testimonials - Social Media, signed it voluntarily and received a copy.

Signature of Individual or Personal Representative:

Printed Name of Personal Representative, if any:

Personal Representative Authority to act for the Individual (Documentation may be requested):

Identity of the Individual verifi ed:

Identity and Authority to Act of Personal Representative verifi ed:

Received and confi rmed for Dr. Smith by:

Signature: Printed Name/Title:

Resource: To review Hales’ HIPAA E-Tool, visit http://thehipaaetool.com/index/contents.F A L L 2 0 1 5 35


Just about every week, a new HIT study confi rms what we already know―physicians and practice management software aren’t always made for each other.

Shopper’s Checklist: Vision Care EHR & PM Softwareby Jay Lodhia, Michelle Stone & Nichol Wills

✔Is the software highly customizable? Does the software have a tiered support system and a ticketing system so we can get any help we need after purchase? Can my staff and I choose how we want to get technical support―phone, web, or live chat?

✔Is the software available either as a local installation or in a

cloud environment―whichever works best for my practice?

✔Does the vendor charge extra to set up additional providers or workstations after installation?

✔Do I get a fully functional sandbox of the free trial software that my practice can test before we make the purchase?

✔Does the software integrate with diagnostic equipment such as auto refractors, photopters, VF units, and cameras. How about digital measuring devices such as M’Eye Fit, Visioffi ce, iTerminal, and Optikam?

✔How can the system help our practice meet PQRS requirements and avoid Medicare reimbursement penalties? Does it interface with IRIS (ophthalmology)? What are your plans for MORE (optometry)?

✔How do you ensure privacy and security compliance?

✔Does the software off er built-in patient engagement with online portal, voice, email, and text messaging features?

✔And, if you have a multi-location practice … How does the software handle scheduling, billing, and optical shop inventory management management across multiple locations? across multiple locations?

ECL HIT HELP

PERFECT FITCrucial Questions to Ask Your EHR VendorThese questions, adapted from the National

Cybersecurity Center of Excellence, cover the topics vendors should be

all over as they look out for your HIT privacy and security compliance needs. Ask a few to keep vendors on their toes and reduce your risk.

VENDOR AGREEMENTS• Are you willing to sign a comprehensive business service agreement?

• Are you willing to confi rm compliance with HIPAA Privacy and Security Rules, and willing to be audited, if requested?

THIRD-PARTY APPLICATION INTEGRATION

• Does my practice need to integrate the cloud-based EHR system with other in-house products, such as practice management software, billing systems, and email systems? If so, what are the implementation procedures and techniques used?

• What security features protect the data communicated among diff erent systems?

PERSONAL OR DEVICE AUTHENTICATION AND AUTHORIZATION

• Do you restrict mobile device types that can access the system?

• What are the security compliance polices for using my own device to access the cloud-based EHR system?

• If a device is lost, stolen, or hacked, what countermeasures prevent protected data from becoming compromised?

• Does the cloud-based EHR system require a user to be authenticated prior to obtaining access to PHI?

Tip: Don’t forget your optical shop (if you have one) when sizing up your EHR options.

Tip: If you plan to use phone support, call the vendors site at diff erent times of the day to ensure they will be there for you.

EYES OPEN

I need to cut a line out of this text above Eyes Open. Anything we can remove?


Hit Help.indd 36 9/29/15 5:31 PM

• What are the authentication mechanisms used for accessing the system?

• Are user IDs uniquely identifi able?

• Is multifactor authentication used? Which factors?

• If passwords are used, does the vendor enforce strong passwords and specify the password’s lifecycle?

• Does the system off er role-based access control to restrict system access to authorized users to diff erent data sources?

• Is the least privilege policy used?

DATA PROTECTION• What measures protect the data stored in the cloud?

• What measures protect the data from loss, theft, and hacking?

• Does the system back up an exact copy of protected data?

• Are these backup fi les kept in a diff erent location, well protected, and easily restored?

• Does the system encrypt the protected data while at rest?

• What happens if you go out of business? Will all clinical data and information be retrievable?

• Do you have security procedures and policies for decommissioning used IT equipment and storage devices which contained or processed sensitive information?

SECURITY OF DATA IN TRANSMISSION• How does the network provide security for data in transmission?

• What capabilities are available for encrypting health information as it’s transmitted from one point to another?

• What reasonable and appropriate steps are taken to reduce the risk that PHI can be intercepted or modifi ed when it’s being sent electronically?

MONITORING AND AUDITING• Are systems and networks monitored continuously for security events?

• Do you log all the authorized and unauthorized access sessions and off er auditing?

• Does the system have audit control mechanisms that can monitor, record, and/or examine information system activities that create, store, modify, and transmit PHI?

• Does the system retain copies of its audit/access records?

• How do you identify, respond to, handle, and report suspected security incidents?

EMERGENCIES• Do you off er the ability to activate

emergency access to its information system in the event of a disaster?

• Do you have policies and procedures to identify the role of the individual responsible for accessing and activating emergency access settings, when necessary?

• Do you provide recovery from an emergency and resume normal operations and access to patient health information during a disaster?

CUSTOMER AND TECHNICAL SUPPORT• What’s included in the customer support /

IT support contract and relevant service level agreements?

• Can you provide a written copy of your security and privacy policies and procedures (including disaster recovery)?

• How often do you release new features? How do you deploy them?

F A L L 2 0 1 5 37


Does a conversation with your EHR vendor or HIT guy make you feel like you’re drowning in a sea of alphabet soup and other assorted incomprehensible jargon? Refresh your memory with this glossary.

Clearinghouse: an intermediary that takes medical billing information submitted by providers and submits it to insurance companies, reducing errors and expediting the reimbursement.

Client Server: an in-house computer system that services computers and hardware within your offi ce.

Cloud Server: an external server hosted by an outside source that you can easily access from your computer, tablet or smartphone―as long as you have an Internet connection.

Interoperability: data exchange between diff erent systems and software applications that allow practices to share health information with their patients, other doctors, hospitals, pharmacies, and other health care entities as needed.

ECL HIT HELP

Meaningful Use (MU): CMS jargon that describes an EP using EHR in a manner that qualifi es for federal health program incentives or exemption from reimbursement penalties. CMS has released the hotly debated standard in three phases: MU Stage 1, MU Stage 2, and MU Stage 3 (which is still brewing at press time). MU is supposed to improve patient care, safety, and privacy.

ONC-certifi ed: describes an EHR technology that complies with the most up-to-date standards mandated by the U.S. Department of Health and Human Services.

Patient portal: a secure online portal though which patients access their personal health information conveniently from anywhere and at any time.

Physician Quality Reporting System (PQRS): how eligible providers EPs report quality of care to Medicare. The program began as PQRI in 2007, a totally voluntary initiative to “support new payment

Quick-Start Guide to EHR Geek Speakby Kristin Hollering

systems that provide more fi nancial resources to provide better care, rather than simply paying based on the volume of services,” according to CMS.

Since 2007, the carrot of the “voluntary” program turned to a stick for eligible parties, with negative 1.5 percent adjustments (penalties) beginning in 2015 for PQRS non-participation in 2013, and negative 2 percent adjustments extending to 2016 and 2017 for non-PQRS participation in 2014 and 2015.

AAO off ers the IRIS tool to help ophthalmologists report PQRS measures. AOA’s MORE also supports PQRS reporting.

For handy links to the current government party line on these terms, visit www.eyecareleaders2020.com/2015/09/22/quick-start-guide-to-ehr-geek-speak/.



A 13-provider eye care clinic is seeing some sweet ROI from an EHR purchase back in 2007―41 percent over fi ve years, according to an article published in Ophthalmology earlier this year.

Bonus: This sweet ROI came in during a period before the feds were off ering payment boosts for Meaningful Use.

Show Us the Numbers$500,250: Amount Asheville Eye Associates spent for hardware and software required to implement EHR.

$600,000: Amount the practice saved in 2011 on reduced back offi ce staffi ng. The practice saw some savings even during the fi rst implementation year because they were able to lay off transcriptionists and medical records staff . That initial savings paid for new HIT support staff hires. By year four, the practice was able to lay off some billing and reception staff and the annual savings from the lean, EHR-enabled staff is now at $600,000 annually.

Between $216,000 and $385,000 a year: Increases in optical shop revenue that study author Dr. Robert Wiggins attributes to electronic prescribing. Patients can still get paper scripts to take somewhere else, but the numbers suggest they relish the convenience of fulfi lling their scripts on site.

$800,000: Increase in annual clinical revenues by the fi fth year after implementation. After the EHR installation, clinician productivity

ECP Gains 41 Percent ROI on EHR Investmentdipped as doctors learned to use it. By the second year, clinician productivity was back up to pre-EHR levels. During the fi fth year, three physicians realized they had more time to see patients and the practice saw an average of 1.23 more patients a day, which created the $800,000 increase.

CAVEAT EMPTORAsheville Eye Associates saw no monetary gains during the fi rst year because they had to hire an HIT guy, scan paper records, and pay for EHR maintenance. Doctors worked longer hours that fi rst year and patients waited longer to see them.

The practice uses scribes who double as technicians so that doctors can focus on the patients, not computers. Even before EHR, however, the practice used scribes.

Dr. Wiggins tells Medscape that his practice is mostly consultive, and that some eye care subspecialties may not see the same kinds of savings from EHR. And, disclosure: Dr. Wiggins received site visit fees from Allscripts during the study period.

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F A L L 2 0 1 5 39


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Compliance.indd 40 9/29/15 5:34 PM

Survival Guide

SURVIVE THE STARK SWAMPWHAT ECPS NEED TO KNOW ABOUT TUOMEY

THE SUNSHINE ACTMAKE SURE WHAT CMS IS SAYING ABOUT YOU IS CORRECT

IS YOUR SAFE HARBOR REALLY SAFE?WHAT YOU NEED TO KNOW ABOUT FMV

AVALANCHEWHAT THE PUF DATA DUMP MEANS FOR ECPS

AUDITORSWHEN AUDITORS ATTACK

Trim Size : 8 .1" x 10.75"

NEW RULES FOR COMPLIANCE SURVIVAL

F A L L 2 0 1 5 41


SURVIVE

THESTARK SWAMP

We get it. The mere mention of the Stark Law is enough to drive you stark raving mad.

Eye care leaders frequently venture into the Stark swamp when they navigate compensation arrangements, consulting contracts, leasing, in-offi ce ancillary services, investment opportunities, and other business deals.

If you want a very-boiled-down-to-the-basics, quick-reference guide to Stark, we’ve got you covered here. For a risk analysis of business deals that may trigger Stark, you should consult an attorney. Stark is one more regulation that keeps health care lawyers in business.

WHAT ECPS NEED TO KNOW ABOUT TUOMEY



WHY THIS MESS?Like many messes, the Stark mess starts with Congress. More than two decades ago, legislators had some good intentions. They wanted to prevent confl icts of interest in medical decision making involving Medicare and Medicaid benefi ciaries. Starting with clinical labs, Congress began to pass laws prohibiting physicians from referring patients to designated health services in which they or their family members had an ownership interest.

Pete Stark is now 82. When he visits the doctor and hears his namesake law mentioned, “I just look the other way and pretend that I had a lot of cousins,” reports The Wall Street Journal.

personal services arrangements, in-offi ce ancillary services, and non-monetary compensation. That’s why most business deals that involve physicians need a fl ock of health care attorneys to review them.

WHAT ARE THE PENALTIES?Stark is not a criminal statute, which means you won’t go to jail if you break only this law. It’s a civil statute enforced by CMS. If you violate Stark, you could face civil monetary penalties and exclusion from Medicare and other federal health programs.

Because the regulation phase dragged on for so long, it’s taken a while for Stark enforcement to get going. But cases like Tuomey and Halifax show that regulators are very, very keen to couple Stark with the False Claims Act to amp up fraud recoveries, observes attorney Wayne

HERE IS THE CURRENT DHS LIST — STARK JARGON FOR DESIGNATED HEALTH SERVICES, WHICH YOU CAN ALSO LOOK UP BY YEARLY CPT® CODE UPDATES.

Clinical laboratory services.Physical therapy services.Occupational therapy services.Outpatient speech-language pathology services.Radiology and certain other imaging services.Radiation therapy services and supplies.

Durable medical equipment and supplies.Parenteral and enteral nutrients, equipment, and supplies.Prosthetics, orthotics, and prosthetic devices and supplies.Home health services.Outpatient prescription drugs.Inpatient and outpatient hospital services.

Where are ASCs on this list?: They’re not there. The Stark law does not apply to ASCs.

TIP: Don’t hold your breath for Phase IV. The rule making has slowed down.

EYES OPEN

Miller. “What might be seen as a technical violation can lead to huge liabilities per provider,” he explains.

WHAT’S NEXT FOR STARK?At press time, the proposed 2016 Medicare Physician Fee Schedule is fl oating two new Stark exceptions―one that would allow entities like hospitals to help you out with non-physician practitioner staff expenses, and one for timeshare leasing arrangements. If you’re looking to get some help from a PA, NP, or visiting independent physician, you could be in luck.

Near the end of the MPFS’s 70-plus pages of Stark musings, CMS proposes some surprising questions, essentially asking if Stark is irrelevant 21st medicine and counterintuitive to coordinated care.

Stay Tuned: For updates on the two proposed Stark exceptions and how the fi nal MPFS aff ects vision care providers, visit www.eyecareleaders2020.com.

WHY DOES ALL THIS SOUND LIKE BAD SCIENCE FICTION SEQUELS?Stark’s oddly symbolic name comes from former Rep. Pete Stark (D., Calif.), a co-sponsor of the initial legislation in the late 1980s and early 1990s who is now retired.

You see all the wacky Roman numerals because the law has been added to and revised multiple times. And the legislation has been so complicated that regulators have scrambled to write rules that interpret and enforce the laws. So the regulations have appeared as Stark Phase I, Phase II, and Phase III.

AND THE EXCEPTIONS?There are tons of them, including exceptions for bona fi de employment,

Pete Stark takes exception to all the exceptions in Stark and says he would not vote for the legislation as it is today.

F A L L 2 0 1 5 43


Why All the Stark Stress?Physician compliance watchers like to stay abreast of the Tuomey and Halifax litigation because they are early instances of the controversial and cumbersome Stark Law being tested in court.

Let’s take a closer look at the Tuomey case, which reared it’s head again this past summer when a federal appeals court upheld a $237 million False Claims Act decision against the Sumpter, SC health system.

The problem: Tuomey paid doctors in ways that violated the Stark law ― tainting 21,730 Medicare claims worth $39.3 million and triggering FCA, government prosecutors say.

JUDGE SLAMS STARKThe appeals court judge upheld an earlier, lower court’s decision against Tuomey. But he also took the opportunity to take the Stark law to task. “It seems as if, even for well-intentioned healthcare providers, the Stark law has become a booby trap rigged with strict liability and potentially ruinous exposure ― especially when coupled with the False Claims Act,” concluded Judge Albert Diaz in the opinion.

5 Lesson’s Learned from Tuomey’s TroublesThe details of the case are a road map for how government regulators and prosecutors approach fi nancial arrangements between physicians and hospitals. You should keep an eye on Tuomey’s biggest lessons as you navigate your own practice’s fi nancial relationships, risk management experts say.

LESSON #1:The health system wanted to do a deal very badly. Why? Area doctors had begun to perform certain outpatient procedures in their own offi ces or in ASCs that they owned themselves. Previously, the doctors had done such procedures at Tuomey facilities, so the health system was trying to regain lost revenue. But shrewd business moves that might make good sense in other industries can trigger compliance woes in health care.

LESSON #2:The physicians’ ten-year contracts required them to perform their outpatient procedures at Tuomey facilities, and their salaries and productivity bonuses were based on a percentage of Tuomey’s net cash collections. The doctors had a fi nancial interest in Tuomey, which implicated Stark. And their fi nancial arrangement with Tuomey did not fall into Stark’s employment exception because their compensation varied with the volume and value of their referrals, the jury concluded. Other features of the employment arrangement, such as the lack of any set hours, also caused it to fall short of the exception.

LESSON #3The court looked not only at money changing hands, but also other things of value. The opinion mentions that Tuomey paid for the physicians’ medical and malpractice liability insurance, as well as billing and collections costs for their practices. One ophthalmologist’s annual income was $500,000 before he entered the contract, and $1 million annually after he entered the contract, the government alleged.

LESSON #4:Tuomey only went through the motions to wedge the arrangements into Stark’s fair market value exception, the government alleges. Tuomey hired an independent valuation fi rm for FMV advice, but didn’t heed it, prosecutors say.

LESSON #5:What started off as a Stark problem because a FCA case. The whistleblower is Dr. Michael Drakeford, an orthopedic surgeon who, at fi rst, was negotiating an employment contract for himself along with the other doctors.

Drakeford began to question the deal when he spotted the Stark problems, and he began to question it even more when an attorney both he and Tuomey hired to review the deal warned them about potential red fl ags in 2005. Drakeford declined the deal. As a qui tam relator, he stands to collect a portion of the civil monetary penalties the government collects.

SURVIVE THE STARK SWAMP



F A L L 2 0 1 5 45


SUNshineTHE

ACT

Some physicians are feeling heat from the Sunshine Act and Open Payments Data. Here’s what you need to know so you don’t get burned.

This past summer, the headlines blazed in the popular press―drug and medical device makers paid a total $6.49 billion to providers in 2014.

MAKE SURE WHAT CMS IS SAYING ABOUT YOU IS CORRECT



Many articles highlighted outlier physicians, such as one nephrologist who pulled in $594,363 in consulting and speaking fees, travel expenses, and meals during 2014. Others mentioned physicians getting what seem like luxury perks unrelated to medical care, including a $65 airport massage, Alcatraz tickets, and a $2,000 payment for a seminar in the Cayman Islands.

Such stories make for good copy, so you can bet the press will continue to highlight the big money that some physicians collect beyond their salaries. Expect a fresh wave of articles every year

when CMS releases updated Open Payments data.

Most articles encourage readers to look up their own doctors on CMS’s site or on easier-to-use sites utilizing the same government data (such as Dollars for Docs). Patients who heed this advice probably won’t learn you accepted half-a-million like the outliers, but they will see the total cost of those lunches the Allergan rep treated you to last year. They may also see consulting fees that seem like small change to you, and big dollars to them.

NOT EGO-SURFING,JUST DUE DILIGENCEYou or your practice manager should drop by the CMS site to check your own data. Think of it as this year’s version of googling yourself.

Why: The data CMS collects and publishes on you―and that sites like Dollars for Docs are mining for their sites―may be incorrect. The fi rst data set (released Fall 2014) covered the last half of 2013. That data contained inaccuracies, so it’s a good idea to check data for 2014.

OPEN PAYMENTS FACT SHEETSunshine Act legislation passed way back in 2010, so you are no doubt familiar with the basics. Here are some clarifi cations on details that confuse many providers.

The Sunshine Act does not require doctors to report anything about themselves. Providing the data is the responsibility of drug and device companies that make the payments, so that’s one piece of red tape you get to skip.

Physicians may review the data prior to publication. See an error? Take it up directly with the company that has reported the data.

Think Open Payments are a pain? At least they’re not Stark. They may well be a less bureaucratically complex way to accomplish the clunky Stark Law’s overall intent.

Open Payments data do not include money companies spend on:

• Samples they leave at your offi ce.

• Independently-administered continuing education.

• Payments to PAs and NPs.

• Payments related to new products awaiting FDA approval. Those payments are made public after FDA approval or four years after the payment, whichever comes fi rst.

Sources: Shantanu Agrawal (Medical Director, CMS Center for Program Integrity) & Theodore Doolittle (health care attorney with LeClairRyan), presenting at the American Health Lawyers Association 2015 Annual Meeting.

Learn Morecms.gov/OpenPaymentsprojects.propublica.org/docdollars

The Open Payments data is brought to you by CGI Federal, which you may remember as the contractor that gave Healthcare.gov its infamously rocky rollout.

EYES OPEN

F A L L 2 0 1 5 47


IS YOUR

SAFE HARBOR

The HHS Offi ce of Inspector General is taking a close look at whether physician compensation arrangements fall into the Anti-Kickback Statute. And the watchdog agency is making it very clear that physicians are just as responsible for compliance as the facilities that pay them.

WHAT YOU NEED TO KNOW ABOUT FMV

REALLY SAFE?



6 WAYS TO ENSURE YOUR COMPENSATION IS FMV

1. Understand that your compensation for the position includes not just your salary, but the entire compensation package―which could include malpractice insurance and other perks. Is your total compensation package at fair market value?

2. Avoid any kind of percentage compensation related to the volume or value of your referrals.

3. Protect yourself and the entity you’re working for by drawing up a written agreement that you and the entity review annually and revise if necessary. The Kosenske case (2009) shows that a written agreement may protect you in court, Miller observes. The written agreement may mention how parties have calculated FMV for your position, note expected hours of service, require time records or reports, and specify an hourly rate.

4. Ask your attorney to review your agreement. Valuation is complicated business. Your attorney will likely evaluate your proposed compensation against data from a valuation fi rm or compensation surveys from groups like the Medical Group Management Association, the American Medical Association, or the American Medical Group Association.

5. Know that special skills or situations could put you above the FMV of doctors in the surveys. For example: Do you have unique qualifi cations or experience? Will you deal with diffi cult cases that most of your peers can’t handle? Are you serving in a rural or remote area?

6. Don’t accept compensation beyond your formal agreement, such as bonuses, side payments, or free items or services. Tip: More-than-once-a-year revisions to your agreement will look shady.

7. Give your compensation arrangement the “jaw drop test,” Miller suggests. If the details or your compensation would make a colleague’s jaw drop with disbelief at the great deal you’ve got, it’s likely not FMV.great deal you’ve got, it’s likely not FMV.

When we issue a fraud alert, you should assume that investigations into that type

of conduct will continue.- HHS OIG Deputy Chief Robert Penezic presenting at the AHLA annual meeting -

“Physicians who enter into compensation arrangements such as medical directorships must ensure that those arrangements refl ect fair market value for bona fi de services the physicians actually provide,” the OIG stressed in a special fraud alert released this past summer.

If a facility hires you because of the referrals you will provide, the OIG could see the arrangement as a kickback―even if referrals are one of many reasons for the gig you have.

“Although many compensation arrangements are legitimate, a compensation arrangement may violate the anti-kickback statute if even one purpose of the arrangement is to compensate a physician for his or her past or future referrals of Federal health care program business,” the alert warns.

The “even one purpose” part is a clear signal that the OIG does not want to mess around. Another clear signal: the “special fraud alert” format. The OIG has released only four in the past decade.

The latest alert mentions recent settlements with “12 individual physicians who entered into questionable medical directorship and offi ce staff arrangements,” but does not divulge further details.

Last year about this time, the OIG issued a “special fraud alert” on clinical laboratory payments to referring physicians. This year’s warning seems to address “physicians” much more directly than last year’s about “physicians” much more directly than last year’s about their own roles in such arrangements.

FAIR MARKET VALUEEven if referrals aren’t the reason a facility has hired you, you still must make certain a safe harbor protects your compensation arrangement. “Safe harbors protect certain payment and business practices that could otherwise implicate the Anti-Kickback Statute,” the OIG explains on its web site. One key safe harbor requirement is fair market value―commercially reasonable compensation for bona fi de professional services.

Why FMV is complicated when physicians are involved:As diagnosticians, physicians are “gatekeepers.” A doctor’s work―by its very nature―refers patients to other health care services such as clinical labs and hospitals. A physician’s care services such as clinical labs and hospitals. A physician’s referrals mean revenue for those entities, and the value of those referrals muddies up the meaning of FMV for everyone involved―physicians, health care entities, and any regulators who may be looking on.

Tricky: There’s no case law that establishes what FMV means for physicians, and the regulators don’t provide concrete guidance, says attorney Wayne Miller, a speaker on concrete guidance, says attorney Wayne Miller, a speaker on Audio Educator. However, you can take practical steps that Audio Educator. However, you can take practical steps that show you’re being paid for the work you do for the entity you show you’re being paid for the work you do for the entity you work for, not for the value of the referrals you generate for work for, not for the value of the referrals you generate for the entity you’re working for.

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WHAT THE PUF DATA DUMP MEANS FOR ECPS

Old School Compliance: The feds create byzantine, impossible-to-follow rules that attempt to regulate every aspect of the health care business. See Stark.

Compliance 2.0: The feds collect and release loads and loads of data. The press, consumer watchdog groups, and perhaps even federal prosecutors pounce on any bad actors the data reveal. See PUF.

AVALANCHE!



Thanks to “data transparency” legislation in the ACA, CMS now releases Medicare billing data for all physicians who submit Medicare claims. They call it the ‘Physician and Other Supplier Public Use File’―‘PUF’ for short. Data are available for 2012 and 2013. The 2013 data set (dumped this past summer)

contained data for 950,000 providers who received a total $90 billion in Medicare payments.

HOW DOES YOUR PRACTICE COMPARE?Not everything about the data dump is gloom and doom. Used strategically, it

can be a free treasure trove of industry benchmarks that can help you analyze your practice’s Medicare reimbursement patterns. To learn more, go to the CMS web site and search “Medicare Provider Utilization and Payment Data.”

MEDICARE BILLINGHow does your eye care practice COMPARE?

Sources: CMS, D

OJ, AAO

, The Wall Street Journal, Bloom

berg Business, USA TO

DAY

90 BILLION INMEDICARE PART B

PAYMENTS[ ]GRAND TOTAL

$166, 745OPHTHALMOLOGY

PART D DRUGS

AVERAGE AMOUNT PER PROVIDER AVERAGE MEDICARE BILLINGS (SERVICES)

$326, 621

AVERAGE NUMBER OF SEVICE TYPES MEDICARE MILLIONS AVERAGE MEDICARE BILLINGS

32 MEDICAREEYE CARE

SERVICES PER OPTHAMOGIST[ ] 5 DOCTORS

RECEIVED MORE THAN $10 MILLION

$74,000PER DOCTOR,

ALL SPECIALTIES

NUMBER OF PROVIDERS EARNING $1 MILLION+ FROM MEDICARE

AVG. % E&M LEVELS, OPHTHALMOLOGY

3,90070%60%50%40%30%20%10%

9211 99212 99213 99214 99215

SOMETIMES THERE’S A GOOD REASON

HIGHEST 2013 BILLERWAS A HEMATOLOGIST WHO SPECIALIZES IN

HEMOPHILIA(MOST REINBURSEMENT WAS FOR EXPENSIVE PART D DRUGS.)

Sources: CMS, D

OJ, AAO

, The Wall Street Journal, Bloom

berg Business, USA TO

DAY(MOST REINBURSEMENT WAS FOR

EXPENSIVE PART D DRUGS.)EXPENSIVE PART D DRUGS.)

(OUT OF 100%)

[ ] PER OPHTHALMOLOGY[ ]

[ ] [ ]

3 Reasons PUF Is a Potential PR Problem for Your Practice1. Most of each year’s data dump shows ho-hum Medicare billing patterns, but there are some outlier

providers with outlandish billing patterns. That makes the annual data dump a treasure trove for reporters looking for a good fraudster story.

Any PUF press coverage your patients saw this past summer reinforced the “Medicare millionaire” stereotype―there are “at least 3,900 of them,” Bloomberg Business announced in a headline. The third highest biller on 2013’s list is an ophthalmologist who raked in “$14.4 million, including $7.7 million for medical services,” USA Today reported. Federal prosecutors have charged the “millionaire” ophthalmologist with fraud.

2. There are lots of ophthalmologists among the 1 percent of providers who get the most money from Medicare, second only to hematology/oncology. Many popular press reports are not explaining crucial backstories to readers―like the fact that Medicare benes are old and suff er from age-related eye disorders that are expensive to treat.

3.The popular press doesn’t always break down for readers the distinction between physician services and the reimbursement for Part D drugs the doctors had to buy―which is why oncologists and ophthalmologists may appear to be rolling in Medicare dollars. In other cases, physicians may be receiving reimbursement services performed with expensive equipment the doctors own, instead of making their patients schlep to the hospital for those services.

What to know: CMS has broken down the diff erence between medical services and Part D drugs. In 2013, average Medicare reimbursement per provider for ophthalmology was $326,621 for medical services and $166,745 for drugs billed with HCPCS codes.

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Trim Size : 8 .1" x 10.75"

MAC | MEDICARE ADMINISTRATIVE CONTRACTORDescription: Private companies that contract with CMS to process, pay, and ensure accuracy of Medicare payments.

Habits: May send ADRs (Additional Development Requests) to providers asking to see documentation supporting Medicare claims. Providers have 45 days to respond.

RAC | RECOVERY AUDIT CONTRACTOR Description: Private companies that contract with CMS to audit all health care companies that submit Medicare claims.

First spotted: In CMS demonstration projects in the mid-2000’s. Contractors and boundaries of regions covered can change yearly.

Habitat: There are four RACs that oversee four regions in the US.

Habits: Feed on the 9-12 percent contingency fees they collect when they hunt down improper payments.

ZPIC | ZONE PROGRAM INTEGRITY CONTRACTOR Description: Closely related to RACs, but tasked with sniffi ng out fraudulent claims, not just improper payments. May refer audits to FBI, DOJ or OIG for further investigation.

PRIVATE PAYERS Description: Insurers looking for overpayments or fraud. Often equipped with more sophisticated software, analytics, and resources than auditors for Medicare and other federal health care programs.

Increased activity: “Data analytics has exploded over last 10 years,” according to Nicholas Messuri, who heads a fraud prevention and recovery unit for a private payer in Massachusetts. Insurers are mining data in a way no one would have ever dreamed of ten years ago, he said at the American Health Lawyers Association Annual Meeting.

Habits: Perceives a red fl ag when analytics reveal a provider with outlier billing patterns. Networks with auditors at other private payers to give them a heads up on the outlier and the billing pattern. This effi cient interspecies communication delays claims to a provider from all payers. “All of a sudden a provider won’t be getting paid by anybody and won’t understand why,” says Jennifer Ecklund, a health care attorney who sometimes represents providers in litigation that insurers bring against them.

WHENAUDITORS

A FIELD GUIDE TO WHO’S AUDITING YOUR CLAIMS

ATTACK



as it can be?

IS YOUR ASCAS PROFITABLE

If you have ownership interest in an ASC, you’re always on the lookout for ways to boost productivity and profi ts. Here are some fresh, fi eld-tested ideas to inspire you.

Donna Giles, RN, BSN, VP Clinical Operations, and Terry Bohlke, CASC, VP Operations of National Surgical Healthcare studied 21 physician-owned ASCs that perform ophthalmic procedures. They presented their fi ndings at the 2015 ASCA Annual Meeting.

No single strategy will raise productivity and profi ts at every ASC. Even ambitious ASCs should try a maximum of seven or eight productivity-boosting moves at a time, Giles and Bohlke caution. Think carefully about what works best for your ASC and monitor your metrics carefully to make certain thatwhat you try is actually boosting your bottom line.


ASC NEW.indd 54 9/29/15 5:39 PM

Simplify your benchmarkingSome ASCs make the mistake of hiring expensive consultants to do complicated metrics based on national data and not necessarily relevant to your ASC, says Giles. The best productivity metrics compare your ASC’s current performance to past performance.

“Where were you last year and how can you beat that?” Bohlke asks. That’s the best way to gauge whether the productivity improvements you’ve implemented really work.

And those complicated daily productivity tools that companies want to sell you? Save some money and develop your own simple metric that doesn’t require loads of staff time to enter data that’s irrelevant to you, Giles suggests. If you have someone on staff who’s good at Excel, you can develop your own simple, customized tool.

Bohlke and Giles recommend your ASC

look at 3 metrics:

1. Total worked surgical staff hours divided by total hours patients are in the OR―“wheels-in to wheels-out.”

2. Total worked staff hours in PreOp and PACU divided by total patient hours in PreOp and PACU.

3. Total worked staff hours divided by total number of adjusted cases.

Make Sure Your ASC Has Strong LeadersThe most successful ASCs display three characteristics: “strong leadership, strict time management, and a culture of effi ciency,” say Giles and Bohlke.

Your ASC can’t improve productivity unless leaders at all levels are willing to have honest conversations with staff about what the metrics say about high, medium, and low effi ciency.

If your ASC has data your managers and staff can look at together, they can have crucial conversations in transparent, non-threatening ways. For example, some PACU staff are really good at moving patients along, says Bohlke. These patients get out the door safely and their satisfaction levels are high. But some PACU staff aren’t as skilled with patient fl ow.

The solution: Talk openly about the balance between productivity, quality, and patient satisfaction. Team up PACU staff with diff erent styles so they can learn from each other.

The solution: Talk openly about the balance between productivity, quality, and patient satisfaction. Team up PACU staff with diff erent styles so they can learn from each other.

Tip: This is where most ASCs have lots of opportunity to improve productivity.

EYES OPEN

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MU Penalties: ASC OphthalmologistsGet a Pass... For NowIf you are an ophthalmologist who performs a lot of ASC procedures, you’re probably sweating the onset of Meaningful Use penalties. Sweat a little less. Congress have given you some temporary relief.

Why You Were WorriedAlthough there are exceptions for some, the HITECH Act of 2009 requires many physicians to use certifi ed EHR in 50 percent of their patient encounters. Those who don’t comply face Medicare reimbursement cuts of up to 5 percent between now and 2018. Ophthalmologists who perform a lot of Medicare-reimbursable procedures are facing signifi cant pay cuts if they haven’t adopted EHR.

The problem: 82 percent of ASCs aren’t using EHR yet, according to data presented at the ASCA annual meeting. Most ASCs use either paper records or digital scans of paper records―not EHR that meets MU, according to Mary Hibdon, an ASCA presenter.

Why: Lawmakers overlooked ASCs in the original HITECH legislation. ASCs were not listed among eligible providers (EPs) and did not get the fi rst wave of MU incentives. So it’s no surprise that there’s no certifi ed EHR available for ASCs.

As a result, most ophthalmologists can’t use EHR in their ASC work yet, and they risk not meeting their MU requirements if they perform a lot of

procedures at ASCs.

Why You’ve Gotten a BreatherThis summer, Congress passed a law that exempts ASC procedures from your MU obligations. Newly passed legistlation states that the exemption lasts until three years after HHS determines, “through notice and comment rulemaking, that certifi ed EHR technology is applicable to the ambulatory surgical center setting.” That means you can meet your “50 percent of patient encounters” MU obligation via offi ce visits only. You get a pass (for now) on ASC encounters.

The MU exemption applies to ophthalmologists who have ownership interests in ASCs, as well as ophthalmologists who don’t have ownership interests, says Kay Tucker of ASCA, which supported the legislation.

Currently, 30 percent of specialists who perform procedures in ASCs are ophthalmologists, according to CMS data. That percentage could decrease as CMS contemplates moving uncomplicated cataract surgeries into in-offi ce surgical suites.

Fewer cataract procedures in your ASC’s future?Medicare is mulling site change for routine cataract surgeries could slash ophthalmic caseloads in ASCs.

At press time, CMS was asking for comments from ophthalmologists “and other stakeholders” on whether in-offi ce surgical suite cataract surgery is a good idea, as well as input from the RUC on what the RVUs should be.

If you have ownership interest in an ASC, this site change could hurt your bottom line. Cataract surgery with IOL insert, stage one, represents almost 17 percent of ASC procedures for all specialties.

Visit eyecareleaders2020.com for the latest updates.


as it can be?


ASC NEW.indd 56 9/29/15 5:39 PM

ASC Compliance: Check Your Practice’s POS CodingFederal auditors are hot on the trail for incorrect place of service coding. The OIG announced this past summer that Medicare may have overpaid $33.4 million to physician practices and $7.3 million to ASC’s in an audit sample.

The culprit: Sloppy POS coding. If your billing staff misidentifi es a service with POS 11 (Offi ce) when it actually took place in an ASC, you’re being overpaid and exposing yourself to audits. Services performed in ASCs need POS code 24.

No one sets out with dastardly plans to incorrectly code POS. Miscoding happens because of ignorance, confusion, or disorganization in the back offi ce. Four things cause incorrect POS coding:

1. Billing staff are often confused by the precise defi nition of “physician’s offi ce” and “ASC.” If your ASC is adjacent to your offi ce, the potential for confusion increases.

2. Many billers are unaware that incorrect place of service coding can cause overpayments, so they don’t pay attention to POS codes.

3, Faulty data entry causes some POS errors.

4. Systemic fl aws in billing software.

Are You Making This Common Cataract Billing Compliance Blunder?

Your ASC can’t improve productivity unless leaders at all levels are willing

to have honest conversations with staff about what the metrics say about high,

medium, and low effi ciency.

Medicare guidelines for billing presbyopia-correcting (PC) and astigmatism-correcting (AC) intraocular lenses have been around for quite awhile, but there is some misinformation fl oating around that’s steering ophthalmologists and ophthalmic ASCs into risky compliance territory, warned Stephanie Ellis at the ASCA annual meeting.

“Some bad information fl oats around” about premium IOLs these days, Ellis says, and it often comes from supply reps who mistakenly tell you it’s okay for physicians to be involved with premium lens transactions. It’s not okay and it hasn’t been okay for a long time.

The ASC must purchase the premium lens and bill the patient for the out-of-pocket costs beyond the $150 that Medicare typically reimburses for standard IOLs. Ophthalmologists should not have their practices purchase the lenses, nor should they bill cataract patients for out-of-pocket premium IOL costs.

If your practice is closely tied to an ASC because of physician ownership interests, your billing staff needs to be especially careful, Ellis stresses. The patient should write the check for premium IOL out-of-pocket expenses to the ASC, not the practice.

HCPCS codes that Medicare considers “premium” are V2788 for PC IOLs such as CrystaLens, ReStor, and Rezoom and V2787 for AC IOLs such as Toric.

It’s a good idea for the ASC to append the -GY or -GA modifi er to the V-code to indicate the patient has signed the ABN, Ellis recommends. ABNs aren’t mandatory because Medicare never covers premium IOLs. But an ABN is a good communication tool to help patients understand what they owe beyond $150 for a standard IOL.ou Making This Common Cataract Billing Compliance Blunder?

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ASC NEW.indd 57 9/29/15 5:39 PM

30 Ways to Boost Your ASC’s ProductivityHuman Resources

1. Set clear expectations during hiring and on-boarding staff .2. Pay bonuses or raises to employees who cross-train.3. Develop a fair staff -fl exing system.4. Review productivity metrics with high, medium, and low performers.5. Off er leadership training that helps junior managers eff ectively coach

and discipline staff .6. Stagger daily staff start times for maximum effi ciency.7. Start each day with a huddle.8. Pre-approve all overtime and monitor overtime reports.9. Consider a “less than 40 hours a week is full-time” policy to

accommodate staff who want to work in the 35-39 hours per week range.

10. Look for opportunities to staff with a higher proportion of part-time staff .

11. Consider a web-based staffi ng tool that allows part-time and PRN staff to fi ll scheduling gaps.

12. Do a cost-benefi t analysis of your ASC’s agency temp usage.13. Evaluate RN duties to see if some could be done by an LPN or CNA.14. Consolidate administrative and management positions.

Facility15. Find and fi x broken equipment or materials shortages that are

causing backlogs.16. Identify and eliminate physician block time utilizations that are

less than 75 percent.17. Look for opportunities to close and consolidate operating rooms

that aren’t being used to their full capacity.18. Review IUSS logs to identify opportunities to decrease rates.

Time Management19. Research and implement best practices for streamlining cataract procedures.20. Roll out an online patient questionnaire to reduce pre-op phone call time.21. Streamline registration time to shorten the time patient must arrive before surgery and reduce pre-op staff ’s workload.22. Implement a system to decrease number of times when information is missing from PPT.23. Improve slow OR turnover.24. Improve late OR starts.25. Look for and manage large gaps in OR schedules.26. Invest in a family paging system to speed up discharge time.27. Implement a patient white board to set discharge goals for 23-hour stays.28. Study Phase II recovery times to discover factors contributing to long lengths of stay.

For ASCs with seasonal fluctuations29. Consider a staff sharing initiative with another facility in a diff erent geographic location.30. Off er staff time off with benefi ts during light seasons.


as it can be?


ASC NEW.indd 58 9/29/15 5:40 PM

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ASC NEW.indd 59 9/29/15 5:40 PM

ZenA

rrrggghhh! The biggest coding change that health care has seen in 30 years is here. ICD-10 brings us 123,000 new codes―some of them nonsensical and some that you’re not even supposed to use (even though they’re in the manual). Experts predict you’ll see claims denials and cash fl ow crunches as you and your

payers adjust to the transition from ICD-9 to ICD-10.The full-on coding catastrophe you’ve been bracing for is bound to get your cortisol

fl owing and your fi ght or fl ight instinct on the alert.Relax … We’re here to help you block out all the noise and achieve a laser-sharp focus on

what eye care leaders need to know. In a few simple lessons, we’ll help you face ICD-10 with confi dence and composure.

Follow us on the path to ICD-Zen.

WHAT YOU MUST KNOW TO MASTER ICD-10 & GET YOUR CLAIMS PAID

THE PATH TO

ICD


ECL-ICDZEN-BC.indd 60 10/1/15 11:09 AM

Zen

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Corn

eal A

bras

ion

The Fundamentals

ICD-10 Code Detail: Corneal AbrasionCategory Etiology, anatomical

site, and severityExtension

1 2 3 4 5 6 7 CHARACTER

5 0 5 0 1 X A Injury of Conjuctiva and corneal abrasion without foreign body, right eye, initial encounter

5 0 5 Injury of eye and orbit

5 0 5 0 Conjunctiva and corneal abrasion w/ FB (etiology)

5 0 5 0 1 Anatomic site (right eye) (2=left)

5 0 5 0 1 X Placeholder code (X)

5 0 5 0 1 X A Initial Encounter (7th digit extension)

You have about four times as many available diagnosis codes to work with as you had under ICD-9, says Jeff rey Restuccio, an instructor at EyeCodingForum.

Where ICD-9 had fi ve available characters, ICD-10 has up to seven characters. The fi rst three characters

before the decimal point denote the category. Ophthalmologists and optometrists most often use the “H” codes in ICD-10 Chapter 7. You’ll also become familiar with the diabetes codes in Chapter 4 and the injury codes in Chapter 19.

The second three characters after the decimal point provide more information

on etiology, anatomical site, and severity. Sometimes there is a seventh character called the extension.

The simplest way to visualize ICD-10’s logic is to stand back and take in how a sample code works. Here is an example, which Restuccio has broken down and mapped out ...

THE PATH TO ICDZen

Make This Your Mantra‘Unspecifi ed’ Is Never Your FriendIf you peruse the available ICD-10 codes, you’ll see ‘unspecifi ed’ crop up over and over again. ‘Unspecifi ed’ is often the only option that comes up when you use simple, GEMS-based ICD-9 to ICD-10 crosswalk tools available online. ICD-10 makes ‘unspecifi ed’ available for times when documentation doesn’t specify laterality.

WHY ‘UNSPECIFIED’ IS LIKE A ZEN KOANParadoxically, ‘unspecifi ed’ looks like an option in ICD-10, but your coder should never have to use it. Your documentation should always specify laterality.

Payers “don’t like ‘unspecifi ed’ in ICD-9 and they will like it even less in ICD-10 because there is rarely a reason the provider would be unable to specify laterality,” explains Leesa Israel of Supercoder.

Some payers may accept ‘unspecifi ed,’ but those with competent edit systems will likely kick those claims out, adds Restruccio.



Payers don’t like ‘unspecifi ed’ in ICD-9 and they will like it even less in ICD-10.

The seventh character isn’t always around, and when it is, it can mean diff erent things depending on what chapter you’re working with.

Example 1: In injury codes, the 7th character delineates whether the patient is being seen on an initial encounter, a subsequent encounter, or a sequela.

Example 2: Glaucoma codes use the 7th character to report the stage.

Tip: What ICD-10 calls a “sequela,” ICD-9 used to call a “late eff ect.” The plural of sequela is “sequelae.”

Focus: Coding PterygiumYou likely have ‘Surfer’s Eye’ documentation habits that were just fi ne under ICD-9, but will wipe you out under ICD-10.

Most providers document pterygium as “temporal” (toward the ears) or “nasal” (toward the nose), says Restuccio. ICD-10 does not use those terms, so “this is an easy one to get wrong,” he warns.

Let’s look at how you’d code a pterygium in the right eye.H11.031 is “double pterygium of right eye.” That means you

have one that’s both temporal and nasal; it’s on both sides, Restuccio says.

The two ICD-10 codes for “peripheral pterygium” in the right eye are “stationary” (H11.041) and “progressive” (H11.051).

Under ICD-9, most clinicians didn’t use the terms “stationary” or “progressive” in a pterygium note; now, your coder needs them to select the correct ICD-10 code, Restuccio says.

Warning: ICD-10 manual off ers coders the option to code the pterygium as “unspecifi ed.” (Example: H11.001, unspecifi ed pterygium of the right eye.) Choosing “unspecifi ed,” however, will get the claim denied.

Payers don’t like ‘unspecifi ed’ in ICD-9 and they will like it even less in ICD-10.

Example 1: In injury codes, the 7th character delineates whether the patient is being seen on an initial encounter, a subsequent encounter, or a sequela.

Example 2: Glaucoma codes use the 7th character to report the stage.

What ICD-10 calls a “sequela,” ICD-9 used to call a “late eff ect.” The plural of sequela is “sequelae.”

Focus: Coding PterygiumYou likely have ‘Surfer’s Eye’ documentation habits that were just fi ne

Most providers document pterygium as “temporal” (toward the ears) or “nasal” (toward the nose), says Restuccio. ICD-10 does not use those terms, so “this is an easy one to get wrong,” he warns.

Let’s look at how you’d code a pterygium in the right eye.H11.031 is “double pterygium of right eye.” That means you

have one that’s both temporal and nasal; it’s on both sides,

The two ICD-10 codes for “peripheral pterygium” in the right eye are “stationary” (H11.041) and “progressive” (H11.051).

“stationary” or “progressive” in a pterygium note; now,

right eye.) Choosing “unspecifi ed,” however, will get

that trickyYou’ll often see the plural form being

used as a singular in ICD-10-speak―though not always. It’s clear the coding gurus haven’t yet decided how to handle the pesky Latin grammar, so best to just go with the fl ow while they work that out.7th

character

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THE PATH TO ICDZen

Relax ... You’Ve Got the Laterality Thing Down Laterality is one aspect of ICD-10 that should be a cinch for ophthalmologists and optometrists, says medical practice consultant Maggie Mac.

The surge of newly available codes under ICD-10 mostly comes from your specialty’s new ability to report laterality in the diagnosis code. Your coders couldn’t code for laterality under ICD-9, but you’re almost certainly reporting laterality in most of your clinical notes already because your coders need it for correct CPT coding and clean claims. If you’re not, you have bigger problems than ICD-10.

So just continue to make sure every clinical note is clear about whether it’s the right eye, the left eye, or both eyes that have the problem. It’s the most important thing you can do in your documentation to prevent miscoding and denials under ICD-10.

One More Reason to Relax ...Medicare Is Giving Do-OversThat post-ICD-10 cash fl ow crunch you’ve been dreading? It might not be as bad as you think.

Medicare won’t deny claims with incorrect ICD-10 codes until October 1, 2016, CMS says.

So just step back you chakra-sucking MACs and RACs. CMS requires federal auditors to cut you some slack for one year while all providers adjust to ICD-10.

As long as you report from the correct ICD-10 category, CMS won’t deny the claim, explains Part B Insider’s Torrey Kim.

Example: If your coder wants to report an anterior subcapsular polar age-related cataract of the right eye, the appropriate code is H25.031. If, however, she mistakenly reports H25.9 (Unspecifi ed age-related cataract), your practice is still coding within the same category and your contractor shouldn’t deny the claim between Oct. 1, 2015 and Oct. 1, 2016, Kim says.

Warning: If you just report H25 (Age-related cataract), you might see a denial because “in many instances, the code will require more than three characters in order to be valid,” CMS says in an FAQ published July 27, 2015.

2 More Warnings: ICD-9 codes kick out claims after October 1, 2015. Some providers have misinterpreted CMS’s one-year grace period as being one of many ICD-10 delays they saw for years and years. Incorrect. Claims systems aren’t able to accept ICD-9 codes starting October 1, 2015, Kim stresses.

The do-over applies to Medicare only. “If you bill your Medicaid provider with the wrong ICD-10 code after Oct. 1, 2015, you’ll most likely face denials,” Kim says. “As for private payers, you must contact them individually to fi nd out if they follow Medicare’s lead on the grace period.”



PUT A Lid On ItICD-10 includes a slew of sixth character options for codes describing eyelid conditions such cysts, vascular anomalies, blepharitis, and more.

EXAMPLES:H00.011: Hordeolum externum, right upper eyelidH01.024: Squamous blepharitis, left upper eyelid

For your coder to select the correct ICD-10 code, your documentation should mention not only whether the left, right eye, or both eyes are aff ected, but also whether it’s the upper or lower lid aff ected.

USE DON’T USE.**1 = RUL (Right Upper Lid) .**3 = Right Eye, unspecifi ed eyelid

.**2 = RLL (Right Lower Lid) .**6 = Left eye, unspecifi ed eyelid

.**4 = LUL (Left Upper Lid) .**9 = Unspecifi ed eye, unspecifi ed eyelid

.**5 = LLL (Left Lower Lid)

Your documentation should be such that coders use only .**1, .**2, .**4, .**5, says Restuccio. The “.**3” and “.**6” options basically say, “I know which eye, but I don’t know which eyelid,” which could trigger denials. The “.**9” says, “I don’t know which eye or which eyelid.” Don’t use those “I don’t know which lid” codes if you want clean claims that go through the fi rst time, Restuccio advises.

Note: There is no “all eyelids” character, so if someone has blepharopchalasis in all four eyelids, your coder would report four ICD-10 codes: H02.31, H02.32, H02.34, and H02.35

The ICD-10 manual includes “unspecifi ed” options for sixth characters that your coder should never use.

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The PaTh To ICDZen

ICD-10 FOCUSCoding Diabetic RetinopathyIn ICD-9, you needed two codes to report diabetic retinopathy, one code for the diabetes and one for the ophthalmic manifestation. In ICD-10, you need only one. Here’s a breakdown from Jeffrey Restuccio.

Some eye care practices will stumble over miscoding, denials, and cash flow problems under when they work submit claims containing ICD-10 codes for diabetic retinopathy, Maggie Mac predicts.

Why? Even under ICD-9, the information required to properly code diabetes and diabetic manifestations is often missing from the doctor’s note.

Here are some tips to help you communicate clearly with your coders and reduce claims denials.

The number one documentation issue for you to work on is specifying whether macular edema is present along with the diabetic retinopathy, says Restuccio. Without that information, your coder can’t fill in the ICD-10 code’s 6th placeholder, where “1” indicates “with macular edema” and “9” indicates “without macular edema.”

Sometimes you can’t tell whether there is macular edema because of a dense cataract or other issue, Restuccio acknowledges. If that’s the case, suspend the claim until you can do an OCT that tells you whether or not there’s macular edema, he advises. An unspecific code on the claim will get it kicked out and denied.

In ICD-10, E10.*** denotes Type 1 DM and E11.*** denotes Type 2 DM. Do not document Non-Insulin Dependent Diabetes Mellitus (NIDDM) or Insulin Dependent Diabetes Mellitus (IDDM), says Restuccio. Those terms are “inaccurate,” “archaic,” and will confuse your coders, he warns.

Tip: ICD-10 uses the term “with hyperglycemia” to describe what many physicians call “inadequately controlled, out of control, poorly controlled, or uncontrolled” DM. If you want to continue to use your usual terms in your documentation, you need to communicate clearly to your coders what you mean so that they can choose the correct ICD-10 code.

Unlike many other ICD-10 codes your practice will use, diabetic retinopathy won’t be coded by eye. You won’t need to document laterality for coding purposes, although you may still want to mention it in your note for clinical reasons.

Ban ‘BDR’ for good. If you are still using the term “background retinopathy” or “BDR” in your documentation, you will confuse your coders and make it harder for them to choose among mild (2), moderate (3), severe (4), and proliferative (5) for the ICD-10 code’s 5th character.

Is there insulin use? If so, submit Z79.4, recommends EyeNet’s Savvy Coder.

Resource: Check out AAO’se diabetes ICD-10 coding decision trees available here: http://www.aao.org/practice-management/coding/icd-10-cm.

What’s Up With That ‘X’ in Some Codes?When you see an ‘X,’ you’re looking at what ICD-10 calls a “placeholder.” Some placeholders allow for future expansion of codes. Some hold the character slot when a sixth character isn’t required but a seventh is, which occurs often for injury codes.

TIP: ‘X’ marks the spot. If the placeholder is missing, the code is invalid and the claim gets kicked out.

EYES OPEN

ICD-10 Code Detail: DB Retinopathy1 2 3 4 5 6 7

E 1 0 Type I Diabetes

E 1 0 3 Diabetic Retinopathy

E 1 0 3 3 Mild=2; Moderate=3; Severe=4; 5=proliferative

E 1 0 3 3 1 with macula edema; 9=w/o

Type 1 DM with moderate nonproliferative diabetic retinopathy

E 1 0 3 3 1 with macular edema

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Poking fun at ridiculous ICD-10 codes is a great stress reliever. Here are some doozies, compiled by health attorney Jack Schroder. “Doctors laugh at this stuff . Staff cry,” Schroder quips.

W56.22xA: Struck by orca, initial encounter

W55.29XA: Other contact with cow, subsequent encounter

Y92149: Hurt at swimming pool of prison as place of occurrence

Y92.253: Hurt at opera house as place of occurrence

Z89.419: Acquired absence of unspecifi ed great toe

S10:87XA: Other superfi cial bite of other specifi ed part of neck

V97.33XD: Sucked into jet engine, subsequent encounter

R46.1: Bizarre personal appearance

Z73.4: Inadequate social skills, not elsewhere classifi ed

Because laughter is good for the soul...9 Outrageous ICD-10 Codes

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Coding GLAUCOMA

Old ICD-9 Way New ICD-10 Way17,000 codes More than 140,000 codes

17 chapters in manual 21 chapters in the manual

3 to 5 characters only Alphanumeric and up to 7 characters

Used V and E codes to report 'supplementary' information Previously 'supplementary' information now woven into main alphanumeric classifcation system

Used E codes to report accidents, poisonings, injuries, adverse eff ects

Uses S and T codes

Didn't use placeholders Uses placeholder 'X' followed by additional characters

Classifi ed injuries by type Classifi es injuries fi rst by specifi c site and then by type

Didn't report laterality Laterality incorporated into code

One code for "routine exam of eyes"--V72.0 Two possible eye exam codes: Z01.00: Encounter for examination of eyes and vision without abnormal fi ndings. Z01.01: Encounter for examination of eyes and vision with abnormal fi ndings.

Used the term ‘senile’ cataract Uses the term ‘age-related’ cataract

Used the term ‘hypermature’ cataract Uses the term ‘morganian type’ cataract

Contained ‘after cataract’ codes Does not contain ‘after cataract’ codes

Uses term ‘late eff ect’ Uses terms ‘sequela’ or ‘sequelae’

The move from ICD-9 to ICD-10 has some signifi cant terminology changes where cataracts are concerned. Your coders should be aware of these changes and be able to select the correct code from your documentation, even if you’re using the ‘old’ terms.

What ICD-9 termed ‘senile’ cataracts have become ‘age-related’ cataracts in ICD-10.

ICD-9 had one code for “hypermature cataract” (366.18). ICD-10 uses the term “morganian type”―a mature cataract in which the cortex has liquefi ed and the nucleus moves freely within the lens, Restuccio.

Example: H25.21 is “age-related cataract, morganian type, right eye.”

CODING CATARACTS

THE PATH TO ICDZen

Your coders will have many more glaucoma codes to choose from in ICD-10 than they did in ICD-9.

Here’s why. Let’s use pseudoexfoliation glaucoma as an example.

Under ICD-9, your coders reported two codes for pseudoexfoliation glaucoma, and the choices were limited.

1. 355.52

2. 365.7*: a second separate ICD-9 code to report the glaucoma stage in the fi fth character.

ICD-10 incorporates both laterality and staging into the available codes so that your coders now have 20 choices for pseudoexfoliation glaucoma alone, says Restuccio.

However, some of those 20 codes aren’t real options, Restuccio stresses. Your coders can kick out 8 of the choices when they remove “unspecifi ed” laterality and “unspecifi ed” stage from

consideration. That leaves your coders with just 12 viable ICD-10 options to report pseudoexfoliation glaucoma.

KEY TAKEAWAY: As long as you document laterality and glaucoma stage in your note, your coders will be able to select the correct code. In ICD-10, your coder will use the seventh character to report the glaucoma stage you’ve documented when it’s required.

What’s the diff erence between “indeterminate” and “unspecifi ed” glaucoma stages?

“Indeterminate” signals that “you haven’t performed your visual fi eld exam yet, the results are inconclusive, or the patient is a bad test taker,” Restuccio explains. “Unspecifi ed” (which has the seventh character “0”) is too vague and will likely get your claim kicked out.



Mouse Model Research Links Gut Bacteria and UveitisGut bacteria may trigger retina-specific T cells to attack proteins in the eye, leading to uveitis.

“What appears to be happening is that [gut bacteria] make some substance that, to the T-cells, looks like a protein from the retina,” study author Rachel Caspi tells The Scientist.

Next on researchers’ agenda: Figure out how this “mimic” trigger works and identify the bacteria and/or proteins involved. Further basic research could help researchers understand not only uveitis but also of autoimmune diseases that affect other parts of the body besides the eye.

Horai R, Zarate-Blades C, Dillenberg-Pilla P, et al. Microbiota-Dependent Activation of an Autoreactive T Cell Receptor Provokes Autoimmunity in an Immunologically Privileged Site. Immunity. 2015. doi: http://dx.doi.org/10.1016/j.immuni.2015.07.014

Cataracts: Drop, Drop Dissolve?Imagine a world where eye drops eliminate

the need for some cataract surgeries.We may be closer than you think,

say researchers who have completed in vitro and in vivo studies. Eye drops containing lanosterol dissolved the

clumped proteins in dissected cataractous lenses from rabbits. The drops also cleared

vision for several live dogs.Our bodies make lanosterol naturally,

and its oily properties protect the skin. Some researchers are skeptical about compounded lanosterol’s potential as a cataract drug. Just because the drops dissolve cataracts in a few animals doesn’t mean they’ll prove effective for people, they point out.

The team hopes to begin testing in humans within two years, says U.S. News & World Report. Researcher Kang Zhang says that even if drug development is successful, the drops won’t dissolve all cataracts—hard cataracts will still require surgical removal, according to PBS Newshour.

[CITE: Ling Z, Chen X, Zhu J, et al. Lanosterol reverses protein aggregation in cataracts. Nature. 2015; 523: 607-611.]

Cataract Stats

Sources: CDC, CMS, National Eye Institute, World Health Organization.

20 million

ECL Eyes on Research

Number of people worldwide who are blind because of untreated cataracts

51%Cataracts cause 51 percent of blindness around the world.

By age 80,

HaLf

[ ]

What Medicare spends annually to treat cataracts 50

million

Between 2000 and 2010, cataract cases in the US rose 20 percent, from 20.5 million to 24.4 million2000 2010

3million

Number of Americans who have cataract surgery each year[ ]

$3.4 million

of all Americans have a cataract or have had cataract surgery.

Cataract cases among Americans will DouBLe by 2050 to

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What’s Your Role in Glycemic Control?Ineffective, concludes a recent study examining diabetes risk assessments performed during ophthalmology visits.

Not that you shouldn’t keep trying, researchers stress. It’s just that it may take interventions from other providers to head off diabetes-related vision loss.

[CITE: Aiello LP, Ayala A, Antoszyk A, et al. Assessing the Effect of Personalized Diabetes Risk Assessments During Ophthalmologic Visits on Glycemic Control. JAMA Ophthalmol. 2015; 133(8): 888-896.]

Severe Vision Loss Strikes South HardestAmericans who live in the South are more likely to have severe vision loss. SVL is least prevalent in the Northeast.

Severe vision loss prevalence is highest among the poor in all regions. Researchers aren’t sure whether poverty leads to SVL or whether SVL leads to poverty, but the cause is likely a combination of the two.

Most common SVL causes: cataracts, diabetic retinopathy, glaucoma, and age-related macular degeneration. Many insurers do not cover the preventative services that can prevent or slow SVL. Medicare, for example, covers comprehensive dilated eye examination “only for persons with diabetes or at high risk for glaucoma.”

[CITE: Kirtland K, Saaddine J, Geiss L, Thompson T, Cotch M, Lee P. Geographic Disparity of Severe Vision Loss — United States, 2009–2013. MMWR. 2015; 64(19): 513-517.]

Why So Many Contact Lens Wearers Are Taking the Red EyeEye care? It’s likely more like “eye don’t care” when it comes to hygiene among your patients who wear contact lenses.

More than 99 percent of contact-lens wearing respondents in a survey sample reported “at least one risky behavior.”

Each behavior the respondents reported raises the risk of eye infections by five times or more, so it’s no surprise that 30 percent of contact-lens-wearing respondents reported having to visit the doctor for red or painful eye at least once.

Each year, patients rack up one million visits for contact lens complications or keratitis, at an annual cost of $175 million. About 41 million Americans wear contact lenses.

[CITE: Cope J, Collier S, Rao M, et al. Contact Lens Wearer Demographics and Risk Behaviors for Contact Lens-Related Eye Infections — United States, 2014. MMWR. 2015; 64(32): 865-870.]

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Contact Lens Wearers Have Different Bacteria In Their Eyes Than Non-WearersMicrobiologists studied hundreds of ocular swabs from 9 people who wore contacts and 11 people who didn’t.

The ocular biota of contact lens wearers were more diverse than those of non-contact wearers―a diversity “that more closely resembles the group of microorganisms of their eyelid skin,” reported researchers who presented at the American Society for Microbiology Annual Meeting.

The eyes of contact lens wearers had “three times the usual proportion of Methylobacterium, Lactobacillus, Acinetobacter, and Pseudomonas bacteria,” which may explain why wearers are more likely to get eye infections such as corneal ulcers.

The Dirty Details

PROVIDER OFFICE

67%

INTERNET

22%11%

WHERE WEARERS PURCHASE LENSES

RETAIL STORE WITHOUT EYE EXAM

of contact lens wearers surveyed reported at least one “risky hygiene behavior.”

99%

Napping in lenses87%

Showering in contact lenses85%

Swimming in contact lenses61%

Topping off disinfecting solution55%

Wearing lenses while sleeping overnight50%

Replacing lenses at longer intervals than recommended50%

Rinsing in tap water36%

Storing in tap water17%

Not washing hands before removing lenses13%

Not using contact lens case9%

Not washing hands before inserting

lenses

4%

ECL Eyes on Research



ECL LAST LOOK

Future’s so bright

$12.3 BillionUp 8.5% YOY




Lenses

Frames

EyeExams

ContactLenses

$2 BillionUp 4.8% YOY

RefractiveSurgery

NEW MARKET: BLUE-LIGHT BLOCKING LENSES95%: Percentage of Americans at risk for digital eye strain

Sources: The Vision Council, Vision Monday,

ESTIMATE OF VISION CARE PRODUCTS AND SERVICESSOLD AT OPTICAL RETAIL LOCATIONS, JUNE 2014 – JUNE 2015

$38.9 BILLION


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