Greetings and thank you for reading the Summer 2019 OOS Newsletter. Your support of our association has never been more important as you will learn from reading articles in this issue regarding scope of practice, reimbursement matters, and proper access to care for our patients.
As has been the norm in recent years, several states continue to face mounting scope of practice challenges from optometry seeking to encroach upon the surgical duties that only ophthalmologists are educated and trained to properly handle. This is not only a concern for protecting our professional duties but a threat to patient safety and appropriate eye care.
States that have successfully warded off these scope battles have been helped by strong support from the ophthalmologists in their state who give to their political action committee. While Ohio has not faced a scope battle challenge in over two decades, our friends at the American Academy of Ophthalmology remind us that the question is not if but when will it occur.
With that important information, I strongly encourage you to support our fund, the Ohio Medical Eye Political Action Committee (OMEPAC) by visiting our website, www.OhioEye.org, and clicking on the yellow donate button on the homepage.
Also, as we seek to increase patient access to quality eye care, the OOS is supporting a national effort lessen the onerous use of prior authorization before medical services can be delivered to patients in need. Read more about that in this issue.
And there are important new developments both at the state and federal level pertaining to physician pay increases under Medicare and in reducing the additional red tape physicians too often must focus on rather than engaging and caring for patients. More details to follow.
Finally, it’s never too early to mark your calendars for the OOS Annual Meeting. Save-the-Date for our next meeting, Saturday, Feb. 29, 2020 in Columbus. More details to come.
Joe Coney, MD
As of July 1, there is no longer state sales tax applied to the purchase of corrective eyeglasses and contact lenses. The change was contained in a bill signed at the end of 2018 by former Gov. John Kasich.
The new law also now classifies prescription eyeglasses and contact lenses as medical devices. The tax exempt status also applies to repair and replacement parts for the prescription eyewear and for prescription sunglasses. Over-the-counter reading glasses and sunglasses without a prescription are taxable.
The tax exempt status is expected to save Ohioans $29 million annually. The Ohio Department of Taxation issued the following guidance regarding the change in state statute for taxes related to glasses and contact lenses:
What the New State Statute Says
Generally speaking, all sales of tangible personal property are subject to Ohio's sales tax unless specifically exempt. R.C. 5739.02 governs sales tax exemptions and includes:
Because the exemption in R.C. 5739.02 requires that a prosthetic device (defined, as of July 1, 2019, to include eyeglasses or contact lenses in R.C. 5739.0l (JJJ)) must be issued pursuant to a prescription, the term "prescription" is defined as:
Any person claiming an exemption from sales tax for sales of prosthetic devices must complete an exemption certificate as required by R.C. 5739.03(8)(1). So, to the extent a vendor or seller of corrective eyeglasses or contact lenses does not solicit a customer to file a blanket exemption certificate to alleviate the responsibility of determining the actual liability of the consumer, this provision will continue to protect the vendor or seller of corrective eyeglasses or contact lenses.
Additionally, upon audit, the Department will make reasonable attempts to work with the vendor or seller to determine taxability, regardless of the exemption certificate. To the extent that a vendor or seller of corrective eyeglasses or contact lenses can identify on the invoice that the sale of corrective eyeglasses or contact lenses is pursuant to a prescription the sale will meet the requirements of R.C. 5739.02(8)(19).
Questions and Answers:
Q: If there is a sale of frames and lenses together on the same invoice, are both items exempt?
A: If the items can be easily identified as a sale pursuant to a prescription, both items sold together are exempt.
Q: If there is a sale of frames only, are the frames taxable?
A: Unless there is a fully-completed exemption certificate on file for the frames or there is evidence that the sale of the frames is a repair or replacement part for previously-exempted corrective eyeglasses, the sale of frames separately is taxable.
Q: If there is a sale of lenses only, are the lenses taxable?
A: If the lenses can be easily identified as a sale pursuant to a prescription, the sale of lenses is considered exempt.
Q: Are "readers" subject to sales tax?
A: Nonprescription "readers" are always taxable unless another exemption would apply. However, the Department would require a fully-completed exemption certificate associated with the sale of this nonprescription item to show the alternative exemption.
Q: Are repair and replacement parts to eyeglasses exempt?
A: Repair and replacement parts of corrective eyeglasses that previously met the exemption are also considered exempt.
Q: Are contact lenses that change the color of the eye considered exempt?
A: If the lenses can be easily identified as a sale pursuant to a prescription, the sale of lenses is considered exempt.
Q: Do I have to get an exemption certificate for each sale of corrective eyeglasses or contact lenses purchased pursuant to a prescription?
A: Ideally, the receipt of the exemption certificate would provide the most protection for the vendor. However, if your records provide clear evidence that the sale of the corrective eyeglasses or contact lenses was issued pursuant to a prescription, the Department would consider those sales exempt.
Gov. Mike DeWine in July signed a new state operating budget but not before vetoing 25 items from the two-year spending plan, including several critical healthcare-related matters that physician groups had opposed.
Two of the more pressing issues of late in healthcare relate to surprise billing and price transparency. Elected leaders took on both issues in the state budget but settled on language that would have been problematic for physicians and drew widespread opposition from the medical community.
On surprise billing, lawmakers attempted to reign in unexpected medical bills sent to patients for out-of-network care that they likely believed was part of their in-network insurance plans. After a compromise between the Ohio House and Senate, legislators decided to require out-of-network physicians be paid whatever the in-network rate is under the patient’s plan.
Physician groups opposed that idea because it does not allow for physicians to negotiate a better, sometimes more appropriate, reimbursement rate. DeWine, hearing the concerns of the medical community, chose to veto the language. He did, however, call on lawmakers and physician groups to continue working on the issue.
On price transparency, lawmakers sought to require physicians provide an itemized price list for the cost of a medical procedure prior to delivering the service – including determining the patients deductible, co-pay, and other out of pocket expenses for ongoing care. After hearing the objections of the physician community, the budget ultimately required the pricing check list only if a patient requested the information for a non-emergency medical situation.
Medical organizations opposed, saying that the language in the budget bill was still too similar to a 2017 state law that was never implemented after the Ohio Hospital Association, Ohio State Medical Association, Ohio Ophthalmological Society, and others sued to block the law as unworkable.
DeWine agree with medical groups and decided to veto the price transparency language from the budget but said that addressing the issue should remain a priority.
The budget did contain a provision for telemedicine/telehealth requiring private insurance companies to offer coverage parity. This means that for any medical service an insurer provides coverage for during an in-person patient visit, that same coverage must be extended for a telehealth visit. The law does not require payment parity, meaning the rate a physician is reimbursed could be different for an in-person and telehealth visit for the same purpose.
OOS Day at the Statehouse
April 3 was Ophthalmology Day at the Ohio Statehouse as the Ohio Ophthalmological Society (OOS) held its annual OOS Advocacy Day.
OOS President Dr. Joe Coney and OOS members Dr. Adam Cloud and Dr. Carl Minning attended the event and met with eight elected leaders or their staffers.
The OOS contingent focused their comments on protecting Save Our Sight funding, stated concerns with pending fireworks legislation, and addressed scope of practice issues. The group also sat in on a House committee meeting and Senate chamber session.
Lawmakers who met with the OOS were:
OOS Joins Push for Prior Authorization Reforms
The OOS has signed on to a letter from the American Academy of Ophthalmology urging Congressional leaders to address prior authorization burdens under Medicare Advantage.
The Academy continues to put pressure on CMS to address prior authorization abuse in Medicare Advantage plans. The excessive use of prior authorization in these plans places administrative burdens on physician practices and delays patients' access to timely care.
The Academy is continuing to work with the Regulatory Relief Coalition, a group of specialty physician organizations committed to advance the improving Seniors Timely Access to Care Act (H.R. 3107). The Academy is urging members of Congress to support and co-sponsor H.R. 3107.
New Medicaid Options Coming Soon; OOS Offers Input for Selection Process
Gov. Mike DeWine has announced that the Ohio Department of Medicaid (ODM) will select new Medicaid managed care partners to provide healthcare insurance for approximately 2.8 million Ohioans. The process is underway and is expected to last at least a year.
ODM earlier this summer invited providers and other groups to offer comments on how the state’s Medicaid process is currently working and how it might be improved.
“Our mission in this process is to focus on the individual rather than on the business of managed care,” DeWine said. “The request for feedback . . . seeks information specifically form individuals receiving Medicaid services, providers and advocates. Their voices are vital to a just and fair managed care program.”
The Ohio Ophthalmological Society (OOS) responded to the request for feedback, sending memo to ODM on July 31. Echoing the concerns of other physician groups, the OOS asked for the Medicaid plans to include more accountability and transparency ensuring patient access to care. The OOS also called for the state’s prior authorization rules be more strictly enforced to cut down on delays in delivering patient care.
The OOS also urged for timely reimbursement payments shortly after claims are submitted and for clear, expedited appeals procedures for delayed claim and payments. As for care coordination, the OOS recommended interpreting services be made standard in managed care plan contracts so that ophthalmologists can meet the growing multi-cultural Medicaid patient-base.
You can read the full memo on the OOS website at www.OhioEye.org.
We are happy to report that our grant application for the 2019-2020 competitive grant cycle was a success! We will be receiving $650,000 from the Ohio Department of Health's Save Our Sight fund to provide more than 18,300 pieces of protective eyewear equipment and educational materials to Ohio youth.
In addition to the equipment, we will be concentrating on expanding our online and social media efforts and creating even better educational information and experiences for our recipients. All sports equipment applications for the new grant year are currently live on our website (www.playhardgear.com) and we encourage everyone to apply.
To date, our program has distributed over 350,000 pieces of equipment and more than 2,000,000 Ohio youth have benefitted in all 88 counties.
The Centers for Medicare & Medicaid Services (CMS has released its proposed physician fee schedule for 2020. Here are the highlights, based on the Academy's early analysis. Because this is a proposed rule, the Academy will work with CMS over the next few months to ensure a final version that is fair to ophthalmologists.
Academy, ASCRS Secure Equitable Cataract Reimbursements
The Academy partnered with the American Society of Cataract and Refractive Surgery in an exhaustive effort to retain reasonable cataract reimbursement for our profession.
CMS today agreed to the rate that the American Medical Association's Relative Value Scale Update Committee (RUC) submitted. Although this is a decrease, the rate is equitable relative to payments of other physician services of similar time and intensity. It is a recommendation to which the Academy and ASCRS agreed.
The RUC is a unique multispecialty committee dedicated to describing the resources required to provide physician services which CMS considers in developing Relative Value Units (RVUs).
In a process that began last year, the Academy and ASCRS negotiated with the RUC for a rate that is based on our members' survey data.
This extensive survey delivered to the RUC a robust data set culled from practicing ophthalmologists. It was combined with careful, sustained negotiations with the RUC. CMS accepted this recommendation for its proposed fee schedule for 2020.
The proposed cataract fees for 2020 are as follows:
Additionally, CMS is recommending Medicare Administrative Contractors set their own prices for new, combined cataract-and-ECP codes.
Despite the decrease, cataract surgery remains valued at the very top of the scale when compared with procedures of similar length. This is an acknowledgement of intraocular surgery's unique intensity and complexity.
CMS is also making cuts to ophthalmoscopy fees. This is a very high-volume procedure, with very low-paying codes. Reimbursements for these codes will be even lower next year because now they will be bilateral instead of being billed on each eye. Physicians will no longer be paid for the initial ophthalmoscopy, only the extended procedure. Codes currently used to bill these procedures will be deleted.
The proposed ophthalmoscopy fees for 2020 are as follows:
The 2020 Conversion Factor
The proposed 2020 conversion factor is 36.0896, which would be up from 36.0391. There is a 0.14% budget-neutrality reduction.
The 2020 conversion factor for ambulatory surgical centers (documented today in a separate proposal) would be 47.827 for facilities that meet quality-reporting requirements, 46.895 for those that do not.
CMS' E/M Proposal
Last year, CMS permanently changed how E/M is reimbursed, collapsing the current five payment levels to just three. This change won't take place until 2021.
At this time, CMS is proposing to replace the impending changes to E/M with a plan put forward by the AMA on guidelines and descriptors in order to place more emphasis on the time required. The proposal would significantly increase the payment for these services in a budget-neutral manner that also negatively affects ophthalmology.
CMS is also proposing not applying these E/M adjustments to post-operative surgical visits that are built into ophthalmology's procedures.
Because of the change to E/M and cataract and ophthalmoscopy codes, ophthalmology would experience one of the largest decreases among all medical specialties.
Quality Payment Program/MIPS Changes
The Merit-Based Incentive Payment System is getting harder. Physicians would need 45 points to pass, up from 30 points, thereby avoiding a 9% penalty. CMS also proposed increasing the cost category weight to 20%, up from 15%, along with fewer exclusions.
The Academy's IRIS Registry remains ophthalmologists' best tool for success in MIPS.
More Analysis Forthcoming
The Academy is reading and analyzing this massive, 1,704-page document (PDF, 7.6 MB). Make sure to visit the 2020 Medicare Fee Schedule page and read Washington Report Express in the coming weeks for more information on how this fee proposal will affect our profession.
For more information, contact Matt Daigle at firstname.lastname@example.org.
Remote Retina Imaging Code Survey Emailed to Select Academy Members
The Academy is preparing to defend one of the profession’s retina imaging codes before the American Medical Association/Specialty Society Relative Value Scale Update Committee.
CPT code 92228 covers imaging of a retina for detection or monitoring of a disease when a remote physician or other qualified health care professional makes a unilateral or bilateral interpretation and report. The Academy is working with the American Society of Retina Specialists to gather new data on the code’s value via a random survey among our community of ophthalmologists.
Watch your email for a survey from AAOdc.email@example.com.
The Academy previously worked with the AMA to expand the definition of CPT code 92228 to remote detection and monitoring for retina disease progression. Any time a definition change takes place, the RUC reviews the code to ensure it is still appropriately valued.
The Academy and our subspecialty partners are allowed to defend the code’s value using our most recent data. The data obtained through this survey will be presented to the RUC for consideration before the committee submits its valuation recommendation to the Centers for Medicare & Medicaid Service.
We highly encourage those who have received the survey to complete it so the dataset will meet the required threshold to be considered robust.
AAO Annual Meeting – Save-the-Date
The American Academy of Ophthalmology Annual Meeting is Oct. 12-15 in San Francisco. To register and for more meeting information, visit: www.aao.org/annualmeeting.
Save-the-Date - The Ohio Ophthalmological Society’s 2020 Annual Meeting will be held on Saturday, Feb. 29 in Columbus. As is the case each year, a robust full-day agenda is being planned with expert guest speakers from Ohio and across the country.
The meeting will include a physician’s conference, workshops for technicians, and the Train-the-Trainer program will return for a second year, expanding to a full day. The Train-the-Trainer program is targeted primarily to technicians and office managers and will provide a variety of HR solutions for training and managing employees.
Additional information will soon be available and accessible on the OOS website at www.OhioEye.org.
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