Risk Management



Comanaging Refractive Surgery Patients (Part 3)

By Paul Weber, JD
OMIC Risk Manager

[Digest, Spring, 2000]

Some managed care patients who have LASIK at high volume/low cost surgery centers, particularly those outside the United States, attempt to return to their regular ophthalmologist for postoperative care. This is an emerging concern for many ophthalmologists, some of whom believe that by providing postop care, they are rewarding the patient for finding the cheapest surgical deal. Others are afraid that the patient may be unhappy with the surgical outcome and in a litigious state of mind. Although it may seem objectionable to treat these patients, it is necessary to analyze each situation before refusing treatment to avoid exposure to claims of breach of contract or malpractice.

Q Am I obligated to provide postop care to patients who had an elective procedure outside their managed care health plan?
A First analyze the “included and excluded services” in the managed care contract. If it is a capitated contract, there may be exclusions for complications or care following a non-covered service (LASIK, PRK, etc.) delivered outside the plan. Under a capitated contract, it is possible you would have to see the patient and not be compensated beyond the capitated fee you would ordinarily receive under the contract. Unfortunately, postop care can sometimes take up quite a bit of an ophthalmologist’s time, especially if the patient has a complication. If this is not a capitated contract but a reduced fee for service, the contract still controls whether or not you are required to see the patient; however, you would be able to charge your customary reduced fee for services provided.

Q If a patient is referred to me by a primary care physician (PCP), can I ask the PCP to refer the patient to another ophthalmologist in the network?
A This may seem to be an appropriate option, but it needs to be considered carefully since there is a chance of straining the referral relationship. “It is crucial that the ophthalmologist personally speak with the PCP and explain the problem. He can’t just send the patient back, and he can’t have one of the staff call the PCP’s office to talk to a staffer in that practice. It must be physician to physician.” (Gil Weber, April 25, 2000.) Also, there is a risk in simply assuming that the patient’s complaint or reason for referral is solely related to refractive surgery. It may be prudent to see the patient to avoid running the risk of missing a problem unrelated to the refractive surgery.

Q What are my risks if I refuse to see a managed care patient for LASIK postoperative care?
A If you refuse to see a managed care patient, you may be in breach of the managed care contract and risk exposure to contractual damages as set forth in the agreement and/or regulatory action. If you refuse to see a patient who has a specific clinical problem, there is risk of exposure to a medical malpractice lawsuit for delaying or failing to provide treatment.

Q Do I have to provide enhancements to managed care patients who had refractive surgery outside the plan?
A If the patient needs an enhancement to an elective surgery not covered by the health plan, you probably are not obligated to provide such care.

Q Can I encourage managed care patients to go back to the surgeon who performed the procedure?
A You may encourage a patient to go back to the surgeon who performed the original procedure; however, as a practical matter, the surgeon may be in Canada or otherwise not be accessible. In any case, it is prudent to document that the patient was given the choice of returning to the original surgeon but elected not to. OMIC’s model form, Assumption of LASIK Post-Op Care, was created for situations involving American patients who have refractive surgery in Canada but can be adapted for use with any managed care patient by amending the last paragraph concerning fees.

The recent publication of the joint position paper on ophthalmic postoperative care by the American Academy of Ophthalmology and the American Society of Cataract and Refractive Surgery again draws attention to the importance of documenting that patients were properly informed and consented to post-operative care being provided by someone other than the operative surgeon. OMIC addressed this issue in the Fall 1999 Digest, and OMIC’s model form, Confirmation of Postoperative Comanagement Selection by the Ophthalmologist, can be used to document the patient’s understanding of comanagement of postoperative care. Please contact the Risk Management Department at (800) 562-4652 or riskmanagement@omic.com to request this form or Assumption of LASIK Post-Op Care form.

Paul Weber acknowledges and greatly appreciates the comprehensive analysis of this issue by Gil Weber, MBA, a managed care consultant who can be reached at www.gilweber.com for more information regarding comanagement and other managed care issues.

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#3. Best at defending claims.

An ophthalmologist pays nearly half a million dollars in premiums over the course of a career. Premium paid is directly related to your carrier’s claims experience. OMIC has a higher win rate taking tough cases to trial, full consent to settle (no hammer) clause, and access to the best experts. OMIC pays 25% less per claim than other carriers. As a result, OMIC’s base rates have consistently averaged approximately 15% lower than multispecialty carriers in the U.S.

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