"When Price Shoppers Come Home"
They may expect you to provide LASIK follow-up care - for a copay. Take these steps before they come knocking.
by Gil Weber, MBA, Consulting Editor
Adapted with permission from Ophthalmology Management
© Copyright, 2000. All rights reserved.
In 1996, I traveled from San Francisco to Los Angeles to have photorefractive keratectomy (PRK). The surgeon had performed the same procedure on my wife's eyes in the Phase III VISX clinical trials, so I knew and trusted him. For me, going to a surgeon I knew was well worth the added expense of airfare and 4 days of hotels and meals in LA.
My surgeon prearranged for the follow-up care with a well-qualified colleague in San Francisco. Of course, I paid fee-for-service for that care. My decision to obtain surgery far from home was sound only because my LA surgeon worked out all the post-surgical details in advance. I was assured continuity of care, my medical records were transferred, and the two physicians worked together as if partners in the same office.
How different that was from the situation ophthalmologists now are starting to see with increasing frequency. Today, patients are price-shopping for laser-assisted in situ keratomileusis (LASIK), sometimes obtaining it far from home, and putting their sight in the hands of a surgeon about whom they know nothing.
Some patients seem unaware of or unconcerned about the problems they may face upon returning home. They may not understand that post-surgical care isn't always included in the surgical fee. And it's quite possible that a far-away surgeon or surgical coordinator has told these patients to go back to their local ophthalmologists for post-surgical care, or if any complications arise.
Unfortunately, nobody discusses this instruction or makes prearrangements with the local physician. When the patient returns home and needs care, all he remembers is being told, "Your doctor will take care of you when you get home. It won't be a problem."
This has created a new set of concerns for you, the physician back home, especially when your patient expects to receive follow-up care or "fixes" for a $10 managed care co-pay. Typically, you're unaware that your patient went elsewhere for the procedure. (He most likely didn't tell you of his plan to go out of the country or to one of the national price-busters.) Now this same patient wants you to assume responsibility — and potential liability — for post-op care. Talk about undermining the physician-patient relationship . . .
When price-shopping patients return to their regular ophthalmologist, expecting to receive care for nothing or next to nothing, chances are good that there will be issues complicating life for both of them.
"Slam dunk" no longer
If in 1996 I had asked a refractive surgeon what appealed most to him about PRK, LASIK or variants of this wonderful emerging technology, he probably would have replied: "It's immune from the cost controls and onerous administrative hassles of managed care."
And to all but a few cynics, it did seem that the procedure would become ophthalmology's magic bullet. You charged $1,500 to $2,000 per eye, cash. A non-covered service. You set the fees, and the HMO didn't get involved.
But now refractive surgery is not turning out to be the "slam dunk" so many of us had envisioned. As described in the April 2000 issue of Ophthalmology Management ("Who Will Control Refractive Surgery . . . HMOs or You?"), HMOs and third-party vision plans are getting involved in refractive surgery — some very involved. Even though the service remains non-covered, many HMOs, in alliance with third-party vision plans, are starting to dictate or at least significantly influence who will provide the service, where and at what fee. If you want access to the health plans' refractive surgery patients, you must play the game by the new rules.
It's clear that in local communities, refractive surgery is not "immune" from managed care. And it's also clear that in some instances managed care plans are creating (perhaps unknowingly) confusion for physician and patient, particularly when it comes to professional and financial responsibility for providing necessary care following this non-covered service. Now add the factor of patients price-shopping for LASIK and traveling out of the local community. What do you have? A very complex issue.
Price-shopping: the antithesis of logical thinking?
No matter how they're insured for medical eye care, patients are price-shopping for LASIK in growing numbers. Because payment will be an out-of-pocket expense — not reimbursed by insurance — they're taking a frightening (but not unexpected) approach to finding a refractive surgeon. They're looking for "cheap."
It's really quite incredible, almost an oxymoron when you think about it. It reminds me of what Alan Shepard said in reference to what he thought as he sat in his state-of-the-art space capsule atop a huge rocket, his life on the line, ready to go into space. "I kept thinking that everything here was built by the lowest bidder."
In some cases, enticed by sophisticated advertising campaigns and lured by bilateral pricing far below typical U.S. "retail" pricing (in some cases even below typical break-even costs), patients are going far outside their local communities, even to Canada. From my home state of Florida, patients are hopping on planes and going to Venezuela or Colombia, which takes approximately the same amount of time as flying from Miami to Toronto.
I suspect that little of this dynamic is fully understood or appreciated by most health plan managers. Certainly, they don't appreciate the collateral damage and fallout that can result when their members return home after shopping for surgical care based on nothing other than "cheap." And that ends up sowing a landmine that can explode when the patient re-enters the managed care system.
The aftershock of cheap LASIK
It's one thing if your patient has a clinically based reason for going elsewhere for specialized surgery. Most ophthalmologists have no problem with the patient returning after that. Providing ongoing, medically necessary care isn't an issue, even if that care is delivered within a managed care setting.
But now your patient goes elsewhere, not because of another surgeon's reputation, but because the price is lower. He's convinced that LASIK is LASIK, a surgeon is a surgeon. And in too many cases he's not cognizant of issues surrounding follow-up care or complications, or of the fact that when he returns he'll be 1,000 miles and a country or ocean away from the operating surgeon.
So your patient goes off and has the procedure, perhaps not understanding that follow-up care back home is not included in the price, and also not fully appreciating that if any complications arise, the cost of that care is not included. Perhaps even worse, your managed care patient may not even care. He's not worried about the cost of any follow-up care or "fixes" because he assumes such care will be covered under his HMO — for a $10 co-pay. In effect, he's consciously playing both ends against the middle; buying "cheap" at the front end and assuming you'll take care of him for little or no cost at the back end.
But will that be the case? Will care be authorized and provided under the patient's HMO major medical policy? Perhaps, but it's certainly not clear across all health plans and all benefit packages.
Mapping your way through this minefield
Eventually patients are going to show up in your office, seeking routine follow-up or a surgical "fix" for LASIK obtained elsewhere. Before this happens, I suggest you examine your provider agreements for answers to some managed care questions. Most likely, you'll find none, so you'll need written clarification from the health plans. Here's what to ask:
Am I contractually required to provide routine follow-up care to patients who've obtained non-covered surgical services from another physician? Even though the original surgery clearly was not covered, does a series of appropriate follow-up visits fall within the definition of covered services?
Am I required to provide surgical "fixes?" If the original, non-covered surgical service went badly, and the patient clearly has a medical need for another procedure (perhaps as significant as a corneal transplant), does that consequence of an out-of-plan procedure now fall within the definition of covered services?
Who's responsible for paying for routine follow-up care of a non-covered service, and what about special considerations? For example, if the health plan is responsible, does the patient need a referral from his primary care physician? If yes, what is the medical necessity that allows — guarantees — payment to you? If it's the patient's responsibility, is there health plan documentation that clearly sets out such responsibility so the patient doesn't go ballistic on you?
If I'm capitated, must I absorb the cost of these services as part of the capitation contract? Don't forget, each time you see one of these price-shoppers you'll receive no added revenue. Yet, you'll incur additional costs. In fact, you're guaranteed to lose money providing follow-up care to these patients.
They generated no fee-for-service surgical revenue for you at the front end, and now you're providing the care that really should have been provided by the operating surgeon. As you can see, capitation doubles the aggravation and sows an additional landmine.
Who is responsible for paying for medically necessary surgical "fixes"? As opposed to the relatively low fees billed for simple office visits discussed in the preceding paragraph, if a surgical procedure is needed you're now talking some serious billed charges if either health plan or patient is responsible.
And if you're capitated, you face a significant, negative impact on your bottom line if obligated to provide uncompensated surgery correcting another, out-of-network surgeon's problems. For example, consider the financial impact to your capitation budget if you have to provide a corneal transplant. That's a financial insult you don't want to bear.
Should you provide appropriate postoperative care or medically necessary "fixes" following non-covered surgery? That, of course, is the $64,000 question. If we were discussing follow-up care or complications of cataract surgery, there would be no question. The original surgery is a covered service, and you'd provide any necessary post-surgical care whether contracted under fee-for-service or capitation.
But here the original service isn't covered. In fact, refractive surgery is probably specifically excluded in the paperwork signed by the patient when enrolling for the HMO; though there may be no mention of refractive surgery in your provider agreement, nor mention of responsibility for follow-up care or complications resulting from the non-covered service.
Most likely, you signed an agreement stating that you will provide all covered services within the scope of ophthalmology. Unless you specifically excluded the services we've been discussing from a capitated agreement, it's reasonable to assume your health plan will consider it covered and expect you to provide the services within your capitation. After all, it's easy for the HMO to define the services as covered if it doesn't have to pay any extra.
On the other hand, there's no telling how things will shake out if your contract with the HMO pays you fee-for-service. The plan may decide some or all of the services aren't covered. This dichotomy puts you in a difficult position, and it means you must address the five bullet points described above and the three below. To avoid stepping on this landmine, you'll want to look into all of these matters ASAP.
To minimize the likelihood of trouble, take these steps:
Clarify financial responsibility in each provider agreement. If a plan is responsible, and if you're currently paid fee-for-service, then you'll need to amend the agreement to add appropriate current procedural terminology (CPT) references and fees.
If you're currently capitated, then you'll need to amend the agreement to exclude follow-up care and enhancements following non-covered procedures done out of plan. Plus, you'll need to negotiate a fee-for-service rate for these services to be paid outside your monthly capitation.
If the patient is responsible, then you must double-check to see that your contract gives you the right to charge the patient for non-covered services at your usual and customary fees. Most provider agreements have such a provision, but I've seen some without. If necessary, amend the agreement.
Get it in writing. If a health plan declares that these services aren't covered under a patient's medical eyecare benefits, you can bet that patient is going to be annoyed. So it's essential that you get something in writing from the plan, making it clear the services are not covered and that you can bill the patient. Also, before delivering such services, be certain that you document the patient's consent to be charged in the medical record.
Ethical and legal responsibilities. Some physicians simply don't want to take on the care of patients who've gone out of the community or out of the country for cheap LASIK, even if they know they'll be paid. It just rubs them the wrong way; they feel their relationship with the patient has been damaged.
Even if you feel this way, I urge you to exercise caution and think carefully before refusing to provide this care. It's essential that you fully understand your ethical and legal responsibilities.
Remember, a medical condition may exist that requires care, and your refusal to see the patient may leave you vulnerable if he files a lawsuit (regardless of whether the problem was related to the LASIK or whether you're seeing the patient under any managed care coverage). Remember also that your refusal to provide care may place you in breach of your managed care provider agreement.
Finally, remember that if the patient is experiencing a less than optimal result from the original surgery, he probably isn't in a good mood. Be careful that you're not caught up in his anger in case he's tempted to sue everyone in sight.
I strongly suggest you pull out your provider agreements now. Go through and clarify with your health plans the points I listed in this article. So the next time a patient shows up at your practice doorstep, expecting follow-up care after price-shopping for cheap LASIK, you'll remain calm and not be hurt financially.
Information on the Net
The Ophthalmic Mutual Insurance Company (OMIC) Web site, http://www.omic.com/, provides a detailed discussion of your ethical and legal responsibilities when patients come to your practice after obtaining cheap LASIK elsewhere.
OMIC has also developed a new form you'll want to request, Assumption of LASIK Post-Op Care. Contact OMIC by phone at (800) 562-6642, ext. 24, or by e-mail at riskmanagement - at - omic - dot - com.
Gil Weber, Ophthalmology Management's consulting editor, is a nationally recognized author, lecturer and practice management consultant to the managed care and ophthalmic industries. He's served as managed care director for the American Academy of Ophthalmology.