Building a successful practice as a glaucoma specialist involves navigating a lot of new territory beyond the OR, from getting the types of cases you want to understanding reimbursement. In this article, I delve into the topic of building a viable practice and answer some frequently asked questions about the buy-and-bill model and adopting new technology.
Managing Practice Activities
Every physician should have a voice in determining the look and feel of their practice, and this requires communication with leadership, staff, and referring physicians. Building these connections fosters collaboration and helps establish a practice identity that aligns with shared goals for the practice.
Get to know the doctors in your community. Tell them about the exciting things you are doing, and they will remember you. In addition, appoint someone on your staff to take charge of your practice’s online and social media presence. This provides another opportunity to celebrate your practice’s accomplishments, such as the new technology you are using or the advanced procedures you offer.
Make yourself available. Be willing to take another doctor’s referral and, after consulting with the referred patient, send the referring physician prompt reports expressing appreciation for the referral and providing the patient’s care plan. If you find that the patient is stable and needs to be monitored, communicate that to the referring physician. You may need to let them know that they (or your optometrist) can monitor the patient for the time being but should send the patient back to you in the future as necessary for subspecialty care.
“How do I get the types of cases I want?”
If you feel you are not getting the types of cases you desire, focus on communication. Meet with your leadership team and let them know your goals and the type of practice you envision. Meet with the staff who manage the schedule and inform them of the types of patients you want to see to help them schedule more effectively for you. Help staff to see the benefits of planning ahead, minimizing wait times, and cultivating a positive patient experience.
Caring for referred patients with complex glaucoma may take a lot of time. You have the opportunity to set a protocol to make these consultations more efficient for the practice and the patients. When receiving a referral for a patient who may need surgery, your front desk staff can obtain past medical records for you to review before seeing the patient. For an effective consult, learn about the patient and the care they have already received ahead of time through documented record reviews, which will allow you to document an individual patient order for necessary tests before they arrive at the office. Because these appointments are typically lengthy, you may want only one or two glaucoma consult referrals on your schedule each day, with a couple of cataract patients in between. Keep the lines of communication open and work with your team.
If you have an MD-OD integrated practice, talk with your ODs about how they can serve patients with stable glaucoma and when referrals are appropriate. It may not be necessary for you to see every patient with glaucoma. Whatever your goal, you should have a say in your schedule and the ability to adjust it as needed for efficiency and patient experience.
Understanding Buy-and-Bill Models
The term buy-and-bill refers to physicians obtaining medications and providing them directly to patients. Recently, it has become a hot topic among policy makers, drug manufacturers, physicians, and patient advocates, prompting a movement to change Medicare Part B, which reimburses the cost of drugs that are typically sold this way. Stay alert for potential changes because they could affect your bottom line.
CMS has begun to address issues with Medicare Part B. The agency has proposed that certain drug products that are “multiple source” or have similar labeling and uses be assigned to the same billing codes. Unlike other facets of Medicare reimbursement, the buy-and-bill model is dynamic and open to change, but change is slow. As the use of biologics and biosimilars grows, the use of buy-and-bill will likely affect more practices. Again, keep an eye on policy and consider engaging with medical specialty groups, lobbies, and congressional representatives to safeguard your positions.
“What are considerations for physicians who practice buy-and-bill?”
Purchasing and storing medications within a practice raises several important considerations. Practices are responsible for medication integrity (ie, refrigeration, expiration dates), inventory control, security, supplier payment terms, payer terms, and the staff time required to manage inventory and prior authorizations. Software refrigerators such as CubixxMD (Besse Medical) record inventory as a medication is removed and include a security feature that limits access to certain employees.
The primary expense associated with the buy-and-bill model is the cost of the medication or devices, so it is crucial to negotiate adequate payment terms. Ask for at least 90 days to receive your insurance reimbursement before your practice must pay for the medication or devices. Reimbursement for new technology proceeds more slowly, so it is essential to ensure that the payer preauthorizes it or confirms its coverage through Medicare. In addition, communicate with your industry representatives, who can help you navigate the reimbursement process.
Adopting New Technologies
The process of adopting a new technology into your practice requires caution and research. First, complete a feasibility analysis considering the appropriate patient population, start-up costs, reimbursement hurdles, utilization, and whether you have a sufficiently engaged and talented billing team.
Adopting new technology requires a commitment to change management. You must have staff who are willing to learn new things. You may find that your OR and clinical teams are excited to learn a new technology when you properly present it to them. However, if you do not effectively engage and prepare your staff, you may not get the excitement and support necessary to implement these changes. Communication is key. Set up a standardized protocol and educate everyone in the practice on it. Participate in staff meetings by providing education and discussing the types of patients you can help with the new procedure. This will help reinforce the changes you request and excite your staff about the new technology.
Being the first practice in an area to adopt new technology has benefits. It can allow you to take on patients you could not before and serve your community in a new way. It can also be a great marketing opportunity, so do not let your results go unnoticed.
“What does it take financially to adopt a new technology?”
Understanding reimbursement for a new technology is a major factor in implementing it in your practice. Often, if a payer is not familiar with the technology, they will deem it experimental until someone convinces them otherwise. Making the case for a new technology is difficult, but it can be done with the help of societies and manufacturers.
Another hurdle to reimbursement are category 3 Current Procedural Terminology codes, which are temporary codes for new technology procedures. CMS does not publish pricing for category 3 codes in its fee schedule. It is up to each Medicare Administrative Contractor to decide whether the technology will be covered and how it will be priced.
Seek guidance from manufacturers. They can provide reimbursement guides with examples of claim forms and Current Procedural Terminology codes you may need to know. Start slowly and consider beginning by treating patients with Medicare because it is typically the most generous payer for new technologies.
Reimbursement Landscape
In general, the glaucoma reimbursement landscape is a dynamic area of the practice to monitor. In 2023, five Medicare Administrative Contractors developed restrictive local coverage determinations (LCDs) on certain MIGS procedures. These LCDs would have had major effects on the future of reimbursement and access to care for patients with glaucoma. Several societies and groups, however, successfully lobbied for these changes to be put on hold, and the LCDs were subsequently withdrawn.
In 2024, the draft policies were revisited and revised, and they are now more palatable than those from 2023. Many of these policies took effect in November 2024. It is essential to review and comply with the updated policies. Stay vigilant and contact your societies if you observe extreme or archaic restrictions that could have far-reaching negative effects.
Conclusion
There are many facets of a successful glaucoma practice, and I have focused on just a few of them here. It will serve you well to stay updated and nimble, concentrating on keeping practice communication positive, providing excellent care to your patients, and allowing your team to get excited right along with you about building a viable, profitable glaucoma practice.
