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SlitLamp provides illuminating e-news for Colorado ophthalmologists. It keeps you in the know on the evolving Colorado health care scene by detailing the latest legislative and regulatory happenings. It also spotlights the information and resources you need for your practice.

 

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Executive Director's Update: It's Getting Hot in Here

Posted By Chet Seward, Tuesday, August 13, 2019

Chet Seward,
Executive Director
With the dog days of summer, the heat is definitely on and I’m not talking about the temperatures in August. I’m talking about Colorado’s activist policy environment on health care issues. 

Concerns about the cost of and access to quality health care are growing in magnitude and they are being voiced by Republicans, Democrats and Independents. Interim legislative committees, a new Polis Administration Office of Saving People Money in Healthcare, and myriad regulatory bodies make for a red-hot environment that offers both opportunities and challenges for ophthalmology.

At CSEPS we know that you depend on us to advocate for your priorities and those of the patients you serve. Collectively across our senior management and lobby team we have almost four decades of experience championing critical public policies. The power of our team also lies in your hands as a member of CSEPS. As a dues-paying member you help provide the resources and content expertise to make sure that our advocacy efforts are prioritized and focused. When things get hot, like they are now, more is needed and the number one means of driving great advocacy efforts is a personal relationship with legislators. Whether you invite them to your practice to see a surgery, meet them for a cup of coffee or just trade a few getting-to-know-you emails or phone calls, investing the time to build and nurture trusting relationships with your state senator and representative is critical. We can help coordinate so just ask. Money also helps and that is why we strongly encourage you to donate to EYEPAC and the CSEPS Small Donor Committee so that we can support policymakers that support ophthalmology’s priorities like ensuring surgery is only done by surgeons. 

Enjoy the final days of summer vacations and lingering high temps. Let’s put this public policy heat to good use.

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The unmet demand for specialty care in Colorado

Posted By Chet Seward, Tuesday, August 13, 2019
Alex Caldwell

new report from the Colorado Health Institute (CHI) finds that there is a significant demand for specialty care in Colorado that is not being met.

Colorado medical specialists would need to provide an additional 634,000 visits annually to meet the unmet demand for care by uninsured people and Medicaid members. CHI determined that Medicaid enrollees are missing out on 99,000 ophthalmology visits, and uninsured Coloradans are forgoing 57,000 visits.

There are limitations to the data: CHI created estimates based on data from the Behavioral Risk Factor Surveillance System and the Medical Expenditure Panel Survey (MEPS) to identify rates of utilization by payer, which may make some gaps appear smaller or larger than they are. And CHI was unable to use local hospital referral rates to check its analysis because hospital system data are not collected with the purpose of estimating unmet demand for specialty care. Still, the data offers a glimpse of differences between Medicaid members and uninsured Coloradans.

CHI's model projects that providing specialty care to fill the unmet demand would cost up to $93 million a year, if reimbursed at the rates private insurers pay providers. However, the report suggests several strategies to provide and fund specialty care, including using telehealth and offering social impact bonds to finance an improved system.

Colorado has made great gains in access to care in recent years, but we know there's still a lot of work to do, especially for people with the most complex health conditions and people who already face barriers to accessing care. This report helps quantify the problem and identify potential solutions.

Read the specialty care access report here.

Alex Caldwell is a director at CHI and lead author of the report.

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Lowering health care premiums: State reinsurance and public option plans

Posted By Chet Seward, Tuesday, August 13, 2019

High health care insurance bills have prompted a flurry of activity in Colorado to bring relief to especially hard-hit areas and groups like the mountain communities and consumers and businesses on the individual and small group health insurance markets.

Gov. Polis recently announced the federal approval of a reinsurance plan aimed at consumers on the individual market that purchase insurance on the state health insurance exchange. The program will enable the state to cover the most expensive medical claims for these patients on the individual market which will help private insurers to lower rates by an expected 18%. The Colorado legislature passed HB19-1168 during the 2019 session to authorize the development of the plan.

Another bill passed in the legislature this year also has the potential to shake up Colorado’s health insurance marketplace. As directed by HB19-1004, the state is in the middle of an aggressive stakeholder process under an ambitious timeline to develop and submit a proposal to the General Assembly concerning the design, costs, benefits, and implementation of a state “public option” for health care coverage. The plan, which must be submitted to the legislature by November 15, 2019, offers opportunities and threats for ophthalmology. A state public option may provide a vehicle to decrease health plan administrative burdens and complexities (i.e. standardizing prior authorizations, benefit plans and contracts) that drive ophthalmology practices crazy, and it could be used to advance the importance of eye care and surgery being done only by surgeons. Efforts to control plan costs could also drive toward more concerning things like provider rate setting and mandatory participation. CSEPS is actively working with other medical societies to shape the final proposal. Watch for more details.

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Out of network bills: New state law and regulation development

Posted By Chet Seward, Tuesday, August 13, 2019

Surprise medical bills from out of network providers continue to be a hot issue nationally and in Colorado. During the last legislative session the General Assembly passed HB 19-1174 which aims to limit the impact of these bills on patients. While CSEPS joined in the fight to help make important changes to narrow the scope of this bill and add arbitration, the final bill creates a payment benchmark. For covered services at an in-network facility from an out-of-network provider, the carrier will pay the provider directly the greater of 110 percent of the carrier’s in-network reimbursement rate for the same service in the same geographic area or the 60th percentile of the in-network reimbursement rate for the same service in the same geographic area for the prior year based on commercial claims data from the all-payer claims database (APCD).

According to the state, the Colorado Division of Insurance (DOI) is developing rules to implement HB 19-1174 along five tracks:

  1. Emergency ambulance services reimbursement methodology regulation
  2. Consumer disclosures regulation
  3. Arbitration program process and arbitrator selection regulation
  4. Center for Improving Value in Health Care (CIVHC)/carrier data concerning payment methodologies for out-of-network providers
  5. Out-of-network utilization reporting and terminology regulation   

The current timeline for these regulations is as follows:

  • DOI intends to have drafts ready to circulate to stakeholders by the end of August
  • DOI will hold/coordinate stakeholder meetings on these regulations in September and October
  • DOI will work to finalize the regulations throughout November
  • DOI will issue these regulations as emergency regulations in December to ensure they are in place before January 1

CIVHC has developed an FAQ regarding the latest information and timeline related to the methodology that will be used and the data elements that will be available to the DOI. Ophthalmologists that bill out of network are encouraged to review this information.

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Have you met with your state representative or senator lately?

Posted By Chet Seward, Tuesday, August 13, 2019

One of the best ways to build relationships with the policymakers that can radically change your practice with a quick vote is to meet with them regularly. Legislators face myriad policy issues and having someone that they know and trust to help them figure out how to vote on topics ranging from general health care to the merits of surgery only being done by surgeons is invaluable. Whether you meet them at the capitol, a coffee shop or even at your practice making the effort is worthwhile. CSEPS can help! Contact Chet Seward in the CSEPS offices to learn more. Summertime is a great time to connect with your legislator. Act now.

Pictured above: Oculoplastic surgeon Michael McCracken, MD, from Parker, wraps up a visit with Rep. Kim Ransom.

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Medicare cataract cuts

Posted By Chet Seward, Tuesday, August 13, 2019

The Centers for Medicare & Medicaid Services (CMS) recently proposed its 2020 physician fee schedule, that included a sizable decrease in cataract reimbursements. According to AAO the cuts:

  • Were targeted by CMS last year under its misvalued codes initiative. 
  • Resulted from CMS asking the American Medical Association's Relative Value System Update Committee (RUC) to recommend reductions based on the procedure's time and intensity, as well as post-operative care.
  • Were opposed by AAO and the American Society of Cataract and Refractive Surgery.
    Cataract surgery fees are likely to be cut 15% beginning in 2020.

The RUC had an intense debate about these proposed cuts with some members proposing decreases by up to 40%. In the end the RUC voted to recommend reducing the fee by 15% and CMS announced that it has accepted that value. A large portion of the cut is due to the loss of payment for a fourth post-operative visit.

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Summer social fun

Posted By Chet Seward, Tuesday, August 13, 2019

Thanks to all those that attended the CSEPS social mixer on July 24 at the Recess Beer Garden in Denver. It was a fun night filled with connections, stories and laughs. These no-agenda mixers are a great way to decompress and reconnect with colleagues. Don’t miss the next one.

Pictured above from left, Drs. Jerry Popham, Chris Thiagarajah, Jacob Koczman, and Chet Roe.

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Executive director's update: A day in the life

Posted By Chet Seward, Friday, June 7, 2019
Clenched. That is how I felt at the very moment that the incision was made during the first eye surgery I ever witnessed. I remember the moment vividly as I breathlessly tried to disappear into the wall in spite of the white bunny-suit of sterile gown, bonnet and mask I was wearing so as to not be a distraction to George Ulrich, MD, as he worked his magic to improve a patient’s vision. I don’t remember what the procedure was, but I do remember the seemingly 0-150 miles per hour intensity of the act that carried potential blindness for a millimeter misstep. I was gripped. And here’s the kicker – so was Rep. Lois Landgraf who was standing right next to me. Throughout it all Dr. Ulrich was cool, calm and collected. It was just another day in the office for him.

This peek into everyday life of an eye surgeon may seem mundane to you, but take it from me it can have a profound and lasting impact. Rep. Landgraf is a strong friend of ophthalmology and a leader on the Colorado House of Representatives Public Health Care & Human Services Committee. At CSEPS we take patient safety seriously and fervently believe that surgery should only be done by surgeons. To busy legislators that have the power to profoundly change the way that you practice ophthalmology in Colorado, seeing is believing. Sometimes all it takes is actually witnessing a surgery to bring wonky policy discussion about safety and scope of practice into a new light. Perhaps most importantly, by sharing what you do every day you have the chance to connect, to understand what a typical day-in-their-legislative life is, and to build a relationship. In that way when a legislator has a question about eye care or anything that pertains to medicine in the future, they will call you first. It truly is day-in-the-life simple and at CSEPS we can make it easy for you to set up a similar surgery site visit by your legislator. We will coordinate the details. Contact me today to get a visit set up this summer with your legislator.

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CSEPS Summer Social: 2019

Posted By Chet Seward, Friday, June 7, 2019
Quick, before the dog days of hit, register now for the CSEPS summer social at Recess Beer Garden in Denver on Wednesday, July 24 from 5:30-8:00 pm. At CSEPS we understand the daily grind of practice, keeping up with busy surgery schedules, battling with payer administrative burdens and balancing all of it with your personal life. At a time when physician burnout continues to be a problem, maybe it is time to give yourself a little break. So kick back with a cold brew and some fun food with your ophthalmology colleagues. Whether you are grateful for the summer heat or just the chance to hang out with friends you may not see very often, this is your chance to celebrate the practice of ophthalmology in Colorado. Plus, registration is free for CSEPS members so consider it a bonus summer happy-hour. Get more information and register here.

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Medicare audit targets for Colorado

Posted By Chet Seward, Friday, June 7, 2019

Finding out that your practice is going to be audited is not something any Colorado ophthalmologist wants to hear. Being informed and prepared is the best defense for this news. CSEPS has learned from the American Academy of Ophthalmology that Colorado practices currently face a number of types of audits. All of them are CMS audits – no Medicare Advantage or commercial plan audits –set forth by Part B and customized by Novitas. CSEPS encourages you and your practice team to review the following information carefully and take necessary steps so that when you are audited the payer cannot recoup money. Start by visiting the expert information at AAO.org/audits. The following is a known list of audit targets for this region:

Office of Inspector General (OIG)

  • Monitor physician payments linked to new Medicare MBI cards that should have been returned to CMS because patient is deceased or never received the new card
  • Administration of Lucentis injections for wet AMD more than once every 28 days (based on local coverage determinations)
  • Billing for a second cataract surgery on the same day
  • Submitting disproportionately more claims for complex than standard cataract surgery
  • Telemedicine services that failed to meet the requirements for billing Medicare
  • Postoperative visits

Contivity: Recovery Audit Contractor (RAC)

  • Cataract surgery: Meeting the payer requirements for CPT codes 66830, 66840, 66850, 66852, 66920, 66930, 66940, 66982, 66983, 66984
  • Excessive units for cataract surgery
  • E/M exams billed same day as minor surgeries with 0-day and 10-day global periods
  • E/M exams billed within global period major surgeries
  • Reporting excessive units of inpatient hospital E/M services
  • Office visits billed incorrectly for hospital inpatients
  • New patient exams including E/M and eye visit codes when not considered new
  • Add-on condes paid without primary code and/or denied primary code
  • Automated global vs. TC/26 split reimbursements
  • Excessive units of initial critical care
  • Part B physicians performing radiology services furnished to inpatients (TC component)
  • Excessive or insufficient drugs and biologicals units billed
  • Exact duplicate claims
  • Skilled nursing facility consolidated billing

Target, Probe and Educate (TPE)

  • Inpatient E/N 99223, 99233
  • Critical care 99291-99292
  • Subsequent inpatient 99232-99233
  • Office new patient E/M 99201-99205
  • Office established E/M 99211-99215
  • Emergency department 99-281-99285
  • Lucentis J2778
  • Eylea J0178

Zone Program Integrity Contractor (ZPIC)

  • The agency investigates suspected fraud, waste and abuse based on provider medical review, beneficiary complaints and data analysis

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