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How will the Election Affect Corneal Transplantation?

While everyone is speculating on what a Trump Administration will mean for the country, SightLife Surgical has been analyzing what it might mean for corneal surgeons.  The biggest change that is anticipated, will be in the potential repeal and replacement of the Affordable Care Act (ACA). This change could result in millions of Americans no longer having access to healthcare and could change the payer mix that your practice experiences currently.  We also have a recommendation for how you can take action to avoid potential issues regardless of what happens with any anticipated reform.


ACA/Medicare Reform:

There are approximately 20 million Americans participating in the ACA (Obamacare).  With the election of Donald Trump and Republican majorities in both the House and Senate, there is momentum to move quickly on the campaign promises to repeal and replace the ACA starting in early 2017. In addition, Medicare has been the premier healthcare program for 57 million seniors since the 1960’s, but the Republicans may look at trying to make systemic changes to this program as well.

Despite the fact that Republicans had victories in both the White House and Congress, a full repeal of President Obama’s health law looks unlikely, at this moment in time.

However, a reform of the government health care system is inevitable, and major changes and cuts in Medicare are likely on the horizon. It has been reported that Republicans would likely begin to implement their plan within the first 6-8 months of the Trump administration.  Particularly with the recent appointment of six-term Republican Dr. Tom Price as the new Secretary of Health and Human Services, who has advocated for significant reforms while in office. Also chosen was Seema Verma, a health care consultant, to head the Centers for Medicare & Medicaid Services. She was the architect of the Healthy Indiana Plan, a pilot program noted for being the nation’s first consumer-direct Medicaid program under then Governor, Mitch Daniels. She continued in that role when Mike Pence became Governor.


2017 Medicare Payments Rates

What we do know is that the proposed Medicare payment rates for 2017 indicate that Ambulatory Surgical Centers (ASCs) will receive a 2.6 percent reduction of their payments for corneal transplant procedures (see Chart 1), while hospital outpatient facilities will receive a 1.1 percent increase in payments (see Chart 2). The 2017 proposed physician fee schedule as not been released yet.

Ambulatory Surgical Center (ASC) National Average
CY 2017 Final Payment Rates
Effective January 2nd, 2017
CPT Code Short Descriptor Subject to Mult
Proc Discount
PI Payment Rate Payment Rate Δ 2016 to 2017
1Q 2016 1Q 2017
65710 Corneal transplant Y A2 $1,793.90 $1,747.45 -2.6%
65730 Corneal transplant Y A2 $1,793.90 $1,747.45 -2.6%
65750 Corneal transplant Y A2 $1,793.90 $1,747.45 -2.6%
65755 Corneal transplant Y A2 $1,793.90 $1,747.45 -2.6%
65756 Corneal trnspl, endothelial Y G2 $1,793.90 $1,747.45 -2.6%
+65757 Prep corneal endo allograft N N1 Packaged N1 n/a
V2785 Corneal tissue processing n/a F4 Reasonable Cost F4 n/a

 

Hospital Outpatient Prospective Payment System (HOPPS) National Average CY 2017 Final Payment Rates
Effective January 2nd, 2017
CPT Code Short Descriptor SI APC Payment Rate Payment Rate Δ 2016 to 2017
1Q 2016 1Q 2017
65710 Corneal transplant J1 5492 $3,380.77 $3,417.32 1.1%
65730 Corneal transplant J1 5492 $3,380.77 $3,417.32 1.1%
65750 Corneal transplant J1 5492 $3,380.77 $3,417.32 1.1%
65755 Corneal transplant J1 5492 $3,380.77 $3,417.32 1.1%
65756 Corneal trnspl, endothelial J1 5492 $3,380.77 $3,417.32 1.1%
+65757 Prep corneal endo allograft N n/a Packaged N n/a
V2785 Corneal tissue processing F n/a Reasonable Cost F n/a


Medicaid Payments For Corneal Tissue

The biggest change that corneal surgeons may see is in the payer mix of their patient base. The expansion of the Medicaid program under the ACA resulted in millions more Medicaid enrollees, but the Trump Administration may try to give state governors more authority over their individual Medicaid health programs. Trump has spoken of moving Medicaid to a block formula (or block grants) that would give individual states funds based on poverty levels. While state government would be responsible for managing their own program, there would be oversight at the federal level. 

Based on a review of Medicaid payments across the country only a handful of states reimburse the full invoice cost for corneal tissue similar to Medicare. There are 14 states that do not even cover the corneal tissue at all, including: Alabama, Alaska, Connecticut, District of Columbia, Iowa, Mississippi, Nebraska, North Dakota, Oregon, Pennsylvania, South Carolina, Texas, Utah, Vermont, West Virginia. The rest reimburse based on a flat fee. This means that the surgeon and eye bank community will need to educate these states to improve the payment paradigm to ensure patients have access to the appropriate care.  In 2015, SightLife was able to educate regulators in Washington state to amend their Medicaid payment policies to move from a capitated fee to match Medicare’s policy of paying the invoiced price.

Another thing that ophthalmic practices across the country may experience is an increase of privately-insured patients. Before this happens, we encourage all corneal surgeons to speak with their practice managers to ensure that their current contracts with insurance companies DO NOT have the corneal tissue bundled with the procedure as they could potentially be losing thousands of dollars per procedure.

SightLife Surgical will continue to monitor any changes that the Trump Administration plans to introduce and analyze how they may impact corneal transplantation.

 



Disclaimer

The information contained in this reimbursement coding guide is provided based on research as of November 30, 2016. Because Medicare (CMS) coding, coverage and reimbursement policies and regulations affecting those policies are subject to frequent change (and often vary from payer to payer), the reader is advised to routinely monitor USA federal coding guidelines and coverage policies to verify that the reimbursement information in this guide is up to date going forward.

Policies and procedures published by payers and agencies such as the Centers for Medicare and Medicaid Services (CMS) take precedence over the information contained herein.

CPT codes copyrighted by the AMA