Making the Co-Management Network Work
Trust Is Key in Two-Way Relationship
By ROB Editors
Participating in a co-management network is an increasingly vital part of the optometric practice. Making that relationship work well is a matter of trust.
Trust is a key element, both for the optometrist who sends the patient to a surgeon for a consultation--and for the surgeon who releases patients post-operatively back to the optometrist.
The co-managing relationship is increasingly common with the aging of the American populace and increasing needs for cataract surgery. This is further driven by the 2005 ruling to permit Medicare reimbursement for premium IOLs that correct for presbyopia.
Here is a primer on making the co-management network work.
KNOW THE PROTOCOLS... AND ADHERE TO THEM
There is no quid pro quo when sending patients for surgery. Any financial remuneration for recommending a patient be seen by a specific surgeon is forbidden and cause for an audit. There can be no sharing of fees. Each doctor can only receive the amount each doctor would receive directly from the patient or from a third party as compensation for the services provided to the patient. Billing and coding are separate from one practice to the other.
NO SET TIMETABLES
There cannot be a pre-set timetable for releasing the patient for post-op care (e.g. “I need every patient back one-week post-op.”). The surgeon must determine when it is appropriate to release the patient. If complications arise, the ophthalmologist will want to keep the patient in his or her care longer. The optometrist and the ophthalmologist need to establish trust so that the best care can be delivered to each patient.
DO WHAT’S BEST FOR YOUR PATIENT
Co-management is driven by what is best for the patient. For the optometrist, a patient in need of cataract removal and an implanted IOL is best served by sending the patient to a skilled surgeon who will be thorough and caring. For the ophthalmologist, a post-op patient is best served by an optometrist who will be conscientious and thorough in the care they deliver.
EVALUATE THE SURGEON YOU ARE RECOMMENDING
Spend time with the surgeon by observing their patient consultation and their surgical expertise. When visiting his or her practice, evaluate the way their staff interacts with patients. Ask yourself, “If I send my patient to this surgeon, what is the quality of the surgery they will receive? Will the surgeon and staff be thorough?” Converesly, the surgeon is asking the same: “If I release this patient post-op, will they receive thorough care? If complications arise, does this optometrist know what to do?”
Typically, surgical groups offer CE opportunities to optometrists to update them about the latest surgical techniques and medical advances. This CE often encompasses lectures, patient grand rounds and surgical observation. The more the OD knows about the surgical procedure performed by the surgeon, the more confident they can be in sending patients, and the more informed they are in the post-op care they deliver.
As co-management networks grow, so do audits. Consultants are available who can monitor your working arrangements and educate you and your staff on proper procedures in delivering care and in billing and coding.
The following interviews reflect how trust and education are the cornerstones of a successful co-management network in Columbus, Ohio.
Richard G. Orlando, MD, FACS, ABES
Columbus Ophthalmology Associates
Columbus and Dublin, Ohio
Dr. Richard Orlando began practice as a solo practitioner in 1983. He is founder of Columbus Ophthalmology Associates, where he also serves as director of small incision cataract surgery. The group includes seven ophthalmologists and two optometrists.
ONE WORD... TRUST
I have always felt the most important reason to send a patient for care to anyone is simply one word: trust. Trust that this endocrinologist will help my diabetics get their blood sugars in the best control. Trust that a certain retinal surgeon will do the best vitrectomy and membranectomy on my patient. Trust that this cardiologist will treat the arrythmia to allow my a patient to live a comfortable life with minimal side effects. If that happens, the patient is truly grateful and appreciative of my recommendation.
KNOW THE OPTOMETRIST WHO IS SENDING THE PATIENT FOR CARE
In almost every case, I know the doctor personally or am familiar with their work. I offer all optometrists the opportunity to observe surgery, see post-ops in our practice, and attend our CE meetings so they can also become familiar with our techniques and the way we will treat their patients.
LITTLE THINGS MAKE A DIFFERENCE IN CARE
In our network, I will call the doctor who sent the patient, and I welcome their call to ask me questions. That may take 10 seconds, but it makes a difference. A happy patient with good results will ensure the optometrist will feel comfortable sending more patients to our office for care.
TAKE ADVANTAGE OF EDUCATION
Our group offers opportunities for optometrists to obtain CE. We have evening lectures and also grand rounds where optometrists can meet patients personally and ask the patient about their surgical experience and how well they see post-operatively. I welcome a doctor who is open to learning, they can visit my office any time. If they are closed to learning, then no thanks.
NO QUID PRO QUO
Co-management rules specifically say that there can be no quid pro quo for a referral.
MAKE IT FORMAL
The optometrist asking us to consult with their patient must send a formal signed agreement from their office before I ever see a patient. This agreement states that the patient agrees to the co management arrangement due to "distance or travel arrangement" or other factors that make it difficult to continue to be under our care. That is the first step.
WHAT’S IN STORE: MSOs
It’s harder and harder to be independent these days. We’re not going back to the margins of 15 years ago, and 20 percent cuts are looming in Medicare. I see the future defined by medical service organizations (MSOs), where care and billing are centralized. It doesn’t make sense for independent practices to invest in expensive computerized systems that are going to be obsolete in a few years. Independents need to form larger organizations to compete with chains and walk-in clinics that are now located in drug stores. We will give up some control, but the economies of scale and centralized operations with MSOs will help us be price competitive in this health care environment. This has to happen in the next five years, or we will be left out.
Duke Dye, OD
KEEP COMMUNICATION CONSTANT
Communication is part of the trust. I don't hesitate to pick up the phone and call the ophthalmologists about patients we've sent to them. We communicate on the results of the procedures, and the follow-up care. I am informed throughout the entire process, even if it's the simplest cataract procedures.
Our patients come away from these surgical procedures extremely pleased. My word-of-mouth recommendations are patient-based. When I send them to someone I trust, the patients know it and it's important to them.
When it comes to billing, it's fairly straightforward. The MDs bill their portion, and we bill ours.
FIND THE RIGHT FIT
Meeting wtih doctors in their practices is important, and it helps me tell the patients what to expect during their experience in the surgeon's office. It helps ease the patient's concerns. I have co-managed patients with large medical practices. Large practices offer the advantage of being able to select surgeons who have particular specialties such as cataracts, cornea, LASIK, and retina.
TAKE ADVANTAGE OF SURGICAL-BASED CONTINUING EDUCATION
Many ophthalmologists offer CE throughout the year. It benefits the optometrist to learn the specifics of a surgical procedure so we can explain the procedure to the patient. Patients will ask us what will happen in the operating room.
At least 70 percent of my required CE is spent with co-managing surgeons. I often shadow a surgeon. This hands-on knowledge enables me to know their specialties and see how they and their staff treat patients.
Duke Dye, OD, can be reached at email@example.com.
Dawn Hartman, OD
Dr. Adina Blum and Associates
FINDING THE RIGHT RELATIONSHIP
There are three optometrists in our practice, and we are very particular about where we send our patients for surgical care . When it comes to needing a consultation with an ophthalmologist, I think, "Who would I send one of my own family members to?"
It took me about three years to develop the informal network I have with ophthalmologists. Ideally, I prefer to meet with the surgeons before sending patients to them, either through meeting them personally, or at CE events. I did my own survey of optometrists to find out which surgeons they used. I also formed relationships with MDs whom I met at continuing-education events.
I spoke with several optometrists in my area to find out which surgeons they used most. Then, as I met the surgeons at CE or communicated with them about mutual patients, relationships began to form at our office. We like to stay in close contact wtih our patients throughout the consult and/or surgery process. We have found that it doesn't take long to determine if a surgeon's patient-management style differs from your own.
Communication is the key. If optometrists are willing to seek guidance as needed, trust develops sooner than later with the surgeon. We both want the same thing--the best possible care for our patients.
When co-managing with a surgeon, the patient's medical insurance is billed. Our practice, which is within a Lenscrafters, is currently undergoing the credentialing and set-up process for Medicare and medical billing. We plan to start medical billing and co-management very soon. What can be difficult these days is that Medicare may not be the patient's primary insurer, and some insurance companies many not accept optometrists as providers.
In terms of CE here in Columbus, The Ohio State University, College of Optometry offers a lot of courses, but I also like to attend CE given by the ophthalmologist we use. I especially like roundtable-format CE, which has six to eight optometrists and one ophthalmologist for each topic. This can be a trust-builder, as it allows optometrists to get to know the surgeons a bit. Instead of being reluctant about asking a question in a room of a few hundred people, I am across the table from the surgeon and feel more comfortable to make inquiries.
I have observed both surgeries and ground rounds, which qualify as CE. It's great to watch the patient on the day of surgery. I recently observed about a dozen cataract surgeries; it's great to see how the surgeons work and observe the patients' experience..
Ohio requires 25 hours of CE per year, and I average about 10 of those hours with a comanaging surgeon.
Dawn Hartman, OD, can be reached at firstname.lastname@example.org
Jim Mason, OD
Pataskala Vision Center
FORGING MUTUAL BENEFITS
Optometry and ophthalmology need to work together and the progressive doctors understand this. Co-managment enables us to get patients to surgeons with whom we are comfortable, and it helps maintain better patient records. It is also a better situation for patients. It means both doctors are on the same page. There have been times I have had to send patients to specialists with whom I don't have a close relationship, and patients can sense the difference. When I send patients to doctors I know well, and they send patients to me, the patients can sense the professional confidence we have developed.
I have had a professional relationship with Dr. Orlando for about 15 years. I am a solo practitioner on the east side of Columbus, Ohio, and he was one of the first opthalmologists to come to the area with whom I felt comfortable. Before he arrived in the area, I had to send patients to downtown Columbus, and there were only two other surgeons in the immediate area, and one was about to retire. Otherwise, the specialists were affiliated with downtown hospitals, and that meant a long drive for my patients.
Co-management is something that is imperative. You need to partner with surgeons to complete your practice. It helps me keep my patients, and it helps the ophthalmologists also. The only way to get complete coverage for patients is by partnering with the other doctors. The surgeons know they need us, too.
CODING AND CE
It's important to make sure you are on the same page, too, when it comes to coding. We have to make sure all the modifier codes are on the forms properly.
While most of my continuing education is not spent with MDs, I have watched surgeries, especially when there are new techniques being developed. I have gotten a lot out of CE given by ophthalmology in the area of practice management. I get a lot of information that I am able to use in my practice right away.
Jim Mason, OD, can be reached at email@example.com
A Co-Management Network for LVC
Thomas D. Gilbert, OD, FAAO
Fresh Look Laser Eye Centers
When patients are sent for laser vision correction, some of the co-management issues remain the same as for cataracts but others differ, says Dr. Tom Gilbert of Fresh Look Laser Eye Centers in Columbus, Ohio. Key among these differences is the elective (and non-reimbursable) nature of LVC. Also, with LVC, patients generally are released for post-operative care the very day of the surgery.
Fresh Look Laser Eye Centers is set up in equal partnership between optometry and ophthalmology. The company is 50 percent owned by surgeon Dr. Charles H. Davis and 50 percent owned by member physician optometrists. The center maintains a co-management network with 80 to 100 optometrists. About 50 network practices are listed on the website (www.freshlooklasik.com) with contact information, making it easy for patients to find their own optometrist or one conveniently located near them. At the center, both member and non-member optometrists co-manage their patients for refractive surgery procedures.
Post-LASIK patients are generally seen at intervals of one day, one week, one month, six months and one year. Complications occur in only about 1 percent of cases, says center director Thomas D.Gilbert, OD, FAAO. Occasionally, complications involve the flap, which is created with a bladeless Intralase technique that has greatly reduced complications overall. Patients sometimes rub their eyes, causing a wrinkle. If this occurs, the patient will return to the center to have the flap lifted, smoothed and refloated.
"Proactive optometrists should embrace laser vision correction because offering the latest treatments will help your practice grow,” Dr. Gilbert advises. “It’s no longer current thinking that sending someone for laser vision correction means they won’t ever buy glasses, sunwear or contact lenses.” He stresses that it is prefereable to schedule your patients for a laser vision correction consultation than to find after the fact that they had it done on their own--and commonly at a center that does not participate in co-management.
“If you participate in offering laser vision correction, you won’t get left behind,” Dr. Gilbert adds. "You need to let patients know that refractive surgery reduces their dependency on eyewear and contact lenses, but it does not always eliminate it. This gives the patient correct expectations for the outcome of LVC."
Dr. Gilbert offers these key points of advice to doctors looking to enter a co-management LVC network:
EDUCATION IS KEY
Laser centers offer optometrists ample opportunities to get CE, and optometrists are invited to observe surgery and participate in grand rounds in order to further their education and ensure their treatment competency.
ASK THE CENTER FOR HELP
Drs. Davis and Gilbert are on call 24/7 to help our member doctors to manage any complications where optometrists feel they need help.
OFFER PATIENTS INFORMATION
Laser centers provide member doctors with information on LVC. More information is available on their websites. Not offering patients information on the latest vision correction options is a good way to be left behind--or lose patients to laser centers that don't co-manage.
YOU WILL SEE THE PATIENT AGAIN
Laser vision correction reduces but does not eliminate the need for eyewear. Explain to patients that following LVC, they still need to see you for a yearly eye health exam, where you can monitor for cataracts, glaucoma, diabetes, hypertension and eye-related diseases. Also, presbyopes easily can be helped with a single-eye near contact lens, readers or with plano-top spectacle lenses.
Thomas D. Gilbert, OD, can be reached: firstname.lastname@example.org.