Eyeworld

Name of Ad Page number 8 We learned from our Reimbursement Review that we were underbilling for Photrexa by about $300 per case – by mistake, we had been billing less than what we actually paid for the drug. — Beeran Meghpara, md 95% of our patients go through the specialty pharmacy model, and it's been a very easy way for us to handle the drug acquisition. — KEVIN TOZER, MD collaboratively with optome- trists who are skilled at fitting specialty lenses in complex eyes to obtain the best visual outcomes after cross-linking. If both eyes are determined to be progressing, it is typi- cally most efficient to sched- ule both eyes from the begin- ning, with the desired interval between treatment dates. The second eye can typical- ly be treated 1 to 4 weeks after the first, although some practices schedule as quickly as just a few days apart. The patient's vision and vision correction options may dic- tate how quickly the second eye can be treated. Getting patients back in contact lenses as soon as possible after cross-linking can improve their visual func- tion and make it easier for patients to move forward with the second eye. Since scleral lenses vault over the cornea, patients can resume habitual scleral lens wear within 1-2 weeks of cross-link- ing. Providers may want to wait longer before fitting a new scleral lens. Soft con- tact lens wear can resume after the corneal epithelium has fully healed. Scleral and other specialty lenses often have a 90-day global period from the lens manufacturer, providing time to adjust new scleral lenses as the cornea changes. The cornea specialist or the specialty lens fitting part- ner should proactively edu- cate patients about what to expect during the first post- operative year as corneal remodeling occurs and why to persist despite discomfort or hassles. It is important for patients to understand that cross-linking will halt pro- gression but will not neces- sarily correct their vision, so as to clearly set the proper expectations. ■ #07 BEST PRACTICE U n d e r s t a n d Y o u r Insurance Contracts for Procedure Sustainability Fortunately, many com- mercial health plans in the U.S.—representing >95% of commercially covered lives— now recognize cross-linking with the FDA-ap- proved iLink sys- tem as a covered service. There is no global period for cross-linking; follow-up care is typically billed as office visits at the appropriate com- plexity level, along with any required imaging. Reim- bursement varies by payer, contract, and geography. Despite coverage policies nationwide, underpayments or claims denials may still occur. If not monitored close- ly, these can undermine the viability of KC services for the practice. Glaukos offers cov- erage and reimbursement support through a Reim- bursement Liaison who can provide education and resources. ■ #08 BEST PRACTICE Understand Coverage vs. Reimbursement Across the Payer Landscape Cross-linking is billed as both a procedure code (CPT® code 0402T) and a drug code (J2787). The photosensitiz- ing drugs may be acquired via the buy-and-bill (B&B) model, in which the prac- tice orders and stocks suffi- cient quantities for upcom- ing procedures, or for each patient individually through a specialty pharmacy (SP), also referred to as "white bag- ging." Depending on the region of the U.S., the prac- tice's payer contracts and the patient's insurance plan, one or the other method, or a combination of the two, may better suit your practice. For some practices, the up -front cash outlay of acquiring Photrexa through B&B can be intim- idating. The SP model eliminates t h a t u p - f ro n t cost. For larg- er practices with more resourc- e s , B & B p r o - vides the prac- tice with greater control over the acquisition pro- cess and may be more convenient. Practices can decide which is their pre- ferred procurement channel. The degree to which SP can lower costs for patients is sometimes underappre- ciated. Beyond checking a patient's medical benefits, SP routinely checks the phar- macy benefits, which may be able to reduce patients' out- of-pocket copay and deduct- ible expenses by significant amounts. ■ 8

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