Optimizing Reimbursement in Private Practice
Despite insurance hurdles, cross-linking can be a practice-building procedure – once you know the ropes
Jack Parker | | Opinion
As a second-generation ophthalmologist in a small cornea practice, I have seen corneal collagen cross-linking (CXL) evolve from an experimental procedure to an out-of-pocket service – and, finally, to a treatment covered by insurance.
Today, the majority of commercial health plans in the US – representing >95 percent of commercially covered lives – now recognize FDA-approved CXL solutions and devices as a covered service. My father and I have been offering CXL (see Figure 1) for several years and have performed more than 750 procedures to date. Today, most of my insured patients are covered and our practice is getting paid fairly – but it wasn’t always that way.
When the payment model for CXL first changed, there was a tremendous amount of confusion on the part of practices and insurance carriers about how to bill for it. We had problems with the insurance carrier classifying FDA-approved CXL as an experimental procedure (it wasn’t); paying for the Photrexa drugs but not the procedure (or vice versa); and establishing non-intuitive and often nonsensical criteria for progression.
In many cases, the procedure was “covered” but not paid at a sustainable level. However, the insurance companies successfully climbed the learning curve, and so did we. We now rarely have a problem getting paid for the procedure (See box: “Billing Essentials”). Here are four lessons we learned along the way:
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