Retinal physicians face increasing pressure from government regulators and payors on various issues. To avoid regulatory scrutiny, it’s vital for practice administrators and owners to examine practice operations carefully and make sure they are in compliance.

Q. How can a practice benefit from rebates for biosimilars?

A. Biosimilars are coming to the market as patent protection on brand biologics expire. Pharmacy benefit managers (PBMs) are tiering biosimilars alongside biologics, which can deter patients from switching from familiar biologics to biosimilars because there is no difference in the patient’s out-of-pocket costs. Providers should have an attorney read the fine print in their PBM contracts carefully, to ensure that savings for biosimilars are not being retained by the PBM by being carved out in a pass-through savings contract provision.

Q. How can a practice keep up with the growing demand for retinal injections?

A. As baby boomers age, the demand for retinal injections has increased, straining the ability of ophthalmologists to keep pace with demand. Although providers such as physician assistants (PAs) and nurse practitioners (NPs) have not traditionally been employed in eye care, there is an opportunity to train this workforce to provide eye-care procedures such as retinal injections. Early evidence shows that NPs asnd PAs are capable of such procedures,^1-3 and giving such responsibility to these health care providers can reduce the strain on ophthalmologists.

Integrating PAs and NPs into care teams in this way can be especially helpful for large, high-volume practices, because this can streamline patient traffic and increase practice revenue. An attorney should confirm that this follows state scope of practice regulations. 

Q. How can a practice avoid claim denials due to overuse of Modifier 25?

A. CPT defines Modifier 25 as “Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure.”^4,5 Overuse of Modifier 25 has led to an increase in enforcement. The Centers for Medicare and Medicaid Services and the Office of Inspector General use data extrapolation to identify and scrutinize the highest users of Modifier 25. These data mining efforts have become more sophisticated. Recently, these agencies have begun targeting high users of Modifier 25 by examining the interservice time built into modifier codes, which can often lead to more than 24 hours of services in a day — referred to by the agencies as an “impossible day.” While this methodology unfairly targets practices that have incorporated advanced technology and increased technician workforce to gain efficiency, government agencies nonetheless rely on the data to allege an “impossible day.” To avoid claim denials, conduct an audit of practices, with the assistance of counsel, to ensure that the retina clinic will not stand out to a government agency as performing “impossible days.”

Q. How can a group practice comply with the Stark law when providing ancillary services?

A. Most retina specialists have spent time trying to understand and comply with the federal Physician Self-Referral Law — often called the Stark law — which generally regulates their financial relationships with third parties and their own respective practices. The in-office ancillary services exception to the Stark law provides the most flexibility to retina specialists to hold ownership interests in physician group practices and share profits from so-called “designated health services” (DHS) provided by the practice if they meet certain conditions. 

Many retina specialists provide ancillary services at satellite locations, including services that they don’t personally perform, such as optical coherence tomography. A retina practice may be in violation of the federal Stark law if it does not: (1) make DHS available at the satellite location at least 8 hours per week, or (2) make DHS and some services unrelated to DHS available at the satellite location for at least 6 hours per week. Because federal and state self-referral and anti-kickback laws are complicated, it can be helpful to consult an attorney to ensure that existing and proposed services comply with all regulations. RP

References

1. Ehlers JP, Baraona J. Use of physician extenders in ophthalmology: pros. Curr Opin Ophthalmol. 2023;34(5):382-385. doi:10.1097/ICU.0000000000000972
2. Persaud-Sharma V, Hooshmand MA. Need for nurse practitioner fellowships in ophthalmology in the USA. J Ophthalmic Vis Res. 2021;16(1):113-121. doi:10.18502/jovr.v16i1.8257 
3. Lee B, D’Souza M, Singman EL, et al. Integration of a physician assistant into an ophthalmology consult service in an academic setting. Am J Ophthalmol. 2018;190:125-133. doi:10.1016/j.ajo.2018.03.033
4. American Medical Association. 2023 Current Procedural Terminology, Professional Edition. American Medical Association; 2023.
5. Sperry BH, Corcoran SL. Coding Q&A: Modifier 25 for same-day exam and procedure. Retinal Physician. 2023;20(4):38,45. Accessed March 11, 2024. https://retinalphysician.com/issues/2023/april/coding-q-and-a-modifier-25-for-same-day-exam-and-procedure