The health care system today is complex for both patients and providers. While patients are always the priority of any health care organization, we deal primarily with providers – ophthalmologists, hospitals and ambulatory service centers (ASC’s) – who work with patients. For that reason, we are focused largely on making their jobs simpler and easier, so they can do more for the patients they serve. One way we are doing that is by examining and improving what’s called “reimbursement.”
Let’s start with some background. In the U.S., corneas cannot be sold, but eye banks like ours do charge a tissue processing fee. That money goes to recovering, processing, and providing the corneal tissue for transplant. Hospitals and ASC’s pay that fee upfront, then are reimbursed by Medicare. Medicare treats the reimbursement process differently than some other surgeries. This is where the process gets tricky and reimbursement can become complicated quickly. For that reason, one of the biggest challenges facing eye banks today is reimbursement policy. In fact, the majority of surgery centers say reimbursement is their number one challenge. Miracles In Sight wants to help make the process simpler and more streamlined for both patients and doctors.
Once these two hurdles are cleared, the next step is making sure the tissue processing fee is billed correctly. Oftentimes, an organization isn’t paid for the tissue and its request is denied by insurance or Medicare because a claim is written inaccurately. This is usually due to an incorrect five-character CPT® code. These are used by insurers to help determine the amount of reimbursement that a practitioner will receive for services provided.
MIS is actively looking to find an answer to this growing reimbursement problem. We are one of only a handful of eye banks in the entire country that is proactively asking customers: what are your reimbursement problems and how can we help?
An example – recently an ASC, with whom we now collaborate, was using an outside billing company that was billing corneal transplants incorrectly – as a result the ASC was losing revenue unnecessarily. MIS stepped in to assist and discovered the client was receiving tissue from a source that did not recover the tissue and did not offer direction on correct billing practices.
One of the first steps we took as the ASC’s new tissue provider was to visit the surgery center to offer onsite education regarding billing practices and tissue requests. MIS maintained constant open communication with the ASC’s staff as they learned and worked through billing protocols. We provided documentation from The Eye Bank Association of America and The American Academy of Ophthalmology regarding corneal transplant reimbursement to assist the practice’s staff. Finally, MIS followed up with staff to ensure reimbursements were received as expected.
Our inspiration for finding innovative solutions comes from collaborating with our clients. What problems have you had with reimbursement in the past? We invite you to share your challenges with us so that we can continue to enable healthcare professionals to achieve the best and most successful outcomes for their patients.