7 financial challenges that ODs will face in 2015

A new year is just around the corner and 2015 will bring a new set of challenges for healthcare professionals in the United States.

We recently asked some ODs what they think are the biggest challenges facing the profession in 2015 and beyond. Here’s our list of seven challenges-and we think all are important.

"The real issues are the move away from fee-for-service and being locked out of providing services altogether, optometric oversupply, and vision care plans getting in the way of optometrists providing services to patients via medical insurance," says Beaverton, OR, optometrist Charles A. McBride. "In the short term in 2015, ICD-10 will command the most attention."

1. ICD-10’s looming deadline

The deadline for ICD-10 is creeping up-although some groups are still pushing lawmakers to delay the implementation yet again-and Rebecca Wartman, OD, recently told Optometry Times that many ODs still aren’t ready.

“I do not think that ODs have spent enough time on ICD-10 yet,” Dr. Wartman says. “Most practices do not have a formal plan for transition. And many ODs are totally relying on their staff to do this for them or their electronic health records (EHRs)s to handle ICD-10-both not great ideas.”

ICD-10 now 1 year away, many ODs unprepared

Some say the new coding system will cut down on coding errors and allow for fewer denials and faster payments because it is a more precise, detailed coding system than its predecessor. But because it contains so many more coding options, practitioners will have to be much more detailed with their patient notes. Dr. Wartman strongly urged ODs to practice using the codes long before implementation occurs.

“Medicine may be banking on the new Congress to push implementation past 2016, but it is inevitably coming,” says Bryan Rogoff, OD, MBA, CPHM, in Baltimore. “If your practice is currently using a certified EHR, the transition should be smooth and require minimal training from your staff. But make sure you are aware of your most used diagnostic and procedural codes in ICD-9 and see how they will change in ICD-10.”

And there are concerns that the system might not work perfectly when implemented, delaying payments. Some consultants recommend practices have three months of cash flow in reserve, just in case.

“Once the change is made, a delay in payments could have drastic effect on reimbursement and timing of payments, which will affect your operational cashflows,” says Dr. Rogoff.

Next: Meaningful use changes

2. Meaningful use changes

Next year, Medicare’s meaningful use (MU) program for EHR will move from incentive to penalty because doctors will no longer be able to apply for MU bonuses, and the bonuses will end in 2016. At the same time, penalties for not entering the MU program will begin next year, beginning at one percent of Medicare payments and moving to three percent by 2017.

Optometry Times’ sister publication Medical Economics recently reported that more than 250,000 eligible professionals will face one percent cuts to their Medicare reimbursements for not meeting MU standards.

3. Rise of high deductibles

Thanks to the Affordable Care Act, more and more patients are purchasing insurance plans, but they are often opting for plans with high deductibles because it means they have lower premiums.

The vision care plan industry’s vertical monopoly

“These individuals may be challenged to pay for services up front before meeting their deductibles and cause delinquent or non-payments to the provider,” says Dr. Rogoff. “ODs may not see this for primary-care exams because managed vision care plans cover these services, but discovery of other ocular health conditions and secondary/tertiary care may fall into this category.  

“ODs should prepare staff to make sure which insurances sit as the primary and secondary before patients come for their appointments,” he says. “Staff can then educate patients if additional services will be needed to control the loss of payments of accounts receivables directly from patients with high deductibles.”

4. Malpractice premiums decrease

After years of increases, malpractice premiums are undergoing a decrease that will continue into 2015. Although some healthcare professionals in certain specialties continue to see high premiums, most are seeing a decrease thanks to tort reforms, which capped economic damages.

Next: CMS Open Payments site

5. CMS Open Payments site

The U.S. Center for Medicare and Medicaide Services (CMS)’s Open Payments website, which outlines any financial relationships healthcare professionals have with healthcare manufacturers, officially went live in September 2014.

“CMS is set to report the first year of open payments, which added approximately 68,000 payment records of transfers to physicians and teaching hospitals from group purchasing organizations (GPOs),” says Dr. Rogoff.

CMS is planning to publish all data, disputed and non-disputed, June 30, 2015. Although Dr. Rogoff says he was unsure if the site would have an effect on the average OD’s salary at this time, he says it would be worth watching for both key opinion leaders and any ODs affiliated with universities.

Open Payments reports available for review

6. PQRS penalties

“Starting 2015, eligible providers, such as optometrists, who do not report specific data on quality measure will be hit with a payment penalties of 1.5 percent of reimbursement of professional fees,” says Dr. Rogoff. “These penalties increase to two percent in 2016 and following years.”

Medicare changes for 2014

Next: Accountable care organizations (ACOs)

7. Accountable care organizations (ACOs)

The era of fee for service is ending, and Medicare Advantage plans will be merging with Medicare shared savings programs (MSSPs), according to Somerset, NJ, optometrist Richard Frankel.

"To put this simply, there will be narrow closed panels under this concept," he says. "If you are not part of the panel, you are precluded from providing medical eye care. We have seen routine eye exams covered by vision care plans at $40 under the Advantage plans with minimal dispensing fees. Unaddressed, this may be optometry's only participation in Medicare. This is why it's so important to get ODs on accountable care organizations (ACOs) or MSSPs panels to preclude this from occurring."

Dr. Rogoff says ACOs provide coordinating care to lower overall medical cost and increasing quality of care for patients. He also echoes Dr. Frankel’s call for ODs to join.

“There is tremendous opportunity for ODs to improve healthcare savings and increase quality for diabetic patients that need frequent monitoring,” he says. “As ACOs and coordinated care increases, ODs should not leave money on the table by not participating. Get in touch with primary-care physicians, chief medical officers, and other key medical decision makers and set meetings how your practice can provide efficient, quality services for their patients. The American Optometric Association (AOA) worked with legislatures to have optometry included with the growing need of affordable eye care, and it is up to ODs to seize the opportunities.”