Technology has certainly changed the way we deliver patient care, and it’s still changing rapidly. But technology has impacted our practices in other ways too—namely, how carriers look at the care we provide via claims data, ICD-10 and clinical care protocols. These new avenues of scrutiny are helping to develop new economic models of care that very well may be the endgame of health care reform.

A Busy Year

The last year has seen a transformation in how the health care system tracks the care each provider delivers on a daily basis. October 1, 2015 saw the implementation of the long-awaited (and feared) ICD-10 codes, and October 26, 2015 saw the very first release of comparative billing reports provided to optometrists across the country. Recently, many providers have received letters from a major health insurer on the reported overuse of the comprehensive ophthalmological exam codes 92004/92014. 

All of this is rooted in the concept of outcomes-based care: rewarding efficient and effective providers while penalizing those who aren’t complying with the federal government’s requirements for reporting quality outcomes and properly using EHR systems (meaningful use).

Under the Microscope

Right now, carrier computer systems are rapidly compiling data on each and every provider on a variety of issues, including how many visits it took to resolve a specific diagnosis, which code was used and whether or not that level of code was appropriate for that patient presentation. Sound a bit Orwellian? Perhaps, but it’s the reality of today’s world of cost containment. 

You can always use your great in-office technology to diagnose, manage and treat patients—if, of course, you meet the requirements of medical necessity as established by your carrier contract and local standard of care. But it’s not even that simple anymore. Algorithms for analyzing clinical care protocols are being developed based on clinical studies and claims data. 

Example: Spending Spree This is what outcomes-based care could look like and how carrier-based analysis could affect future payment systems.  A patient presents with classic dry eye complaints: end-of-day CL discomfort, fluctuating vision when blinking, photophobia and burning. You complete a comprehensive exam because it’s been two years since the patient last saw you. You also order a dry eye workup for the following week, consisting of every diagnostic test you can think of. In the meantime, you put the patient on a pharmaceutical agent—not because of clinical signs, but because that’s what you heard at a lecture somewhere. Finally, you schedule follow-up visits every two months. At the first follow-up visit, you put an amniotic membrane on both eyes because another lecture said this was a great first-line therapy without any supporting clinical evidence. Overall, you cost the health care system roughly $4,000 in reimbursements.

Here’s what’s happening behind the scenes in the example: Carriers are looking at the specific CPT code and ICD-10 codes, the frequency of use and the consistency of ancillary testing in combination with pharmacy claims. Why did you perform a comprehensive exam on a patient who presented with complaints of dry eye? That could be considered performing an inappropriate level of care based on the patient complaint. On an ongoing basis, they are comparing your clinical care profile to that of other practitioners of your specialty group and, most importantly, comparing your outcomes. 

If you cannot demonstrate that your care profile was necessary based on documented clinical signs and symptoms at each stage of care, and that your overall care was better than someone who achieved the same outcome at a lower cost, you will face some tough questions about what you did, why you did it and what documented clinical standard of care you were following.

With today’s technology, we can provide diagnostic and point-of-service care we could only dream of a few years ago. But it also allows carriers to dynamically analyze our care to ensure we are providing the most effective outcomes in the most efficient manner—and we have to pay the price if we aren’t measuring up. It’s sobering, to be sure, but to claim ignorance of this in today’s world won’t change the reality. 

Send questions and comments to ROcodingconnection@gmail.com.