Co-Management of Postoperative Care

The debate about co-management of surgical postoperative care began in 1992 with landmark changes in Medicare payment to physicians, and continues today. Legal, medical, and economic issues are involved. The government’s concern over possible abusive referral arrangements and violations of federal and state anti-kickback statutes continues. While co-management of cataract postoperative care is the single most frequent application of this concept within the Medicare program, it is useful to know that this protocol was never widely adopted until recently. From 1996 to 2010, co-management of cataract surgery with IOL (i.e., 66982, 66984) increased from 10% to 19% of all such cases within the Medicare program, and over 20% in 2012, where it remains.

Some Medicare administrative contractors (MACs) publish bulletins with specific coverage policies on postoperative co-management. These bulletins describe circum-stances that merit this approach and are, therefore, covered by Medicare. In those instances where physicians do not fall within the coverage guidelines, MACs would not reimburse claims for postoperative co-management. More significantly, in postpayment review, claims that do not meet the MAC’s guidelines may be considered “false claims” subject to civil and/or criminal sanctions.

While these local policies do not extend to all parts of the country, they represent an important indication of shifting sentiment at Medicare, as well as a likely harbinger of future changes in other venues. Interestingly, in early 2000, the American Academy of Ophthalmology (AAO) and the American Society of Cataract and Refractive Surgery (ASCRS) issued a joint policy statement, which states that postoperative co-management should be “an exceptional rather than a routine occurrence” and incorporates much of the language contained in the Medicare bulletins (see Appendix). Since then, the organizations have become less aligned and, in August, 2016, ASCRS published an updated document. This is somewhat less restrictive and emphasizes that co-management is the patient’s option (see Appendix).

This monograph will address the important elements of a successful co-management protocol within the Medicare program. We also discuss co-management for refractive procedures such as LASIK. Co-management of refractive procedures is outside of the Medicare program but utilizes many of the same principles.

A note of caution: This discussion addresses Medicare Part B: “regular” or “original” Medicare. In 2017, about one third of all Medicare beneficiaries are enrolled in a replacement Part C plan, known as Medicare Advantage (MA). MA plans are usually structured as preferred provider organizations (PPOs) or health maintenance organizations (HMOs). While the MA plans are required to provide the same basic package of Medicare benefits as regular Medicare, many offer additional benefits, such as vision plans. MA plans are not required to adhere to the same payment schedule or payment terms as regular
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Medicare; we frequently find that they establish their own rules about bundles that may differ significantly from regular Medicare.

 

 

 

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