Policyholder Services

I am the supervising physician for a tele-ophthalmology reading center in which retinal photos taken in primary care offices are evaluated and interpreted by trained non-physicians for signs of diabetic retinopathy. Does my OMIC policy cover me for this activity?

It is not uncommon for trained, qualified non-physician readers to participate in the screening of diabetic retinopathy, and literature indicates that non-physician readers may be as good as comprehensive ophthalmologists at interpreting results. However, this activity is not without risk. The level of exposure varies based upon the training and qualifications of the reader, technical issues regarding the camera system used, communication to the patient regarding the limited scope of services provided, protocols for handling non-diabetic pathology, and the duties and responsibilities of the supervising physician. Some of these risks may be mitigated by the contract language between you and the reading center.

Whether the physician’s policy would respond to a resulting claim from such screening activities would depend upon the facts of the case, including the physician’s role in the screening process. For example, coverage would apply to the supervising physician for the review of retinal photos identified by the screeners as suspicious of non-diabetic pathology or for providing a second opinion when there is uncertainty about the reading. OMIC’s policy includes coverage for the insured’s direct patient treatment, including not only making diagnoses and rendering opinions to a patient but also consulting about a patient with another health care provider. Coverage also extends to the physician for his or her vicarious liability coverage for direct patient treatment provided by a person acting under the supervision, direction, and control of the insured, provided the person was acting within his or her scope of training and licensure. Coverage does not apply, however, for allegations against the insured as a medical director of any entity not named in the Declarations. In addition, no coverage would apply to the non-physician readers unless they are employees of the physician and rendering services for the direct benefit of the physician’s practice.

Under Section VII. Additional Benefits, Part B. Broad Regulatory Protection, OMIC provides insured ophthalmologists with legal expense reimbursement coverage, including fines and penalties where allowed by law, for billing error proceedings. To minimize the risk of fraudulent billing claims, physicians must use caution when coding these screening activities. CPT code 92250 is a physician-based service; physicians must provide direct input on each billed procedure to meet the «interpretation and report« requirements established by Medicare.

For additional information regarding diagnostic reading services, please read the lead article, “Hidden Costs of Non-Traditional Revenue Sources,” and “Policy Issues: Coverage for Non-Traditional Services” in the Spring 2008 Digest.