Toa Newsletter

Continued from page 5Texas Medical Association:WelcomeNewMembersProvisionalR. Wayne Bowman, MDDallasJeremy Cefalu, MDTylerRoy E. Lehman, MDShermanKyle Varvel, MDBryanWilliam Waldrop, MDDallasDevin M. West, MDWichita FallsFellowMahdi Rostamizadeh, MDMcAllenResidentGrant Justin, MDSan AntonioRavi H Patel, MDTaylorMichelle Berger, MD, TOA past president, rotated off theTMA Interspecialty Society Committee on December 31.Dr. Berger served as TOA’s alternate delegate to the TMAHouse of Delegates in this role for over 16 years. Luckily forus, Dr. Berger continues to represent medicine as TMA’streasurer. We thank Dr. Berger for her continued service.Dr. Berger will be succeeded as our ISC alternate delegateby Austin member Haumith Khan-Farooqi, MD. Dr.Khan-Farooqi’s two-year term begins January, 2019.2018 Straatsma Awardee: Preston Blomquist, MDCongratulations to Preston Blomquist, MD, the recipient of this year’s StraatsmaAward for Excellence in Resident Education, presented by the American Academyof Ophthalmology and the Association of University Professors of Ophthalmology.This award recognizes and celebrates Dr. Blomquist’s achievements as a residencyprogram director in ophthalmology.Over his 16-year tenure as the residency program director for the Departmentof Ophthalmology at The University of Texas Southwestern Medical Center, Dr.Blomquist has directed 163 residents, thus far. He is described as a passionate advocatefor resident rights and recognized for his support of comprehensive training for allgraduating ophthalmology residents and for increasing the required surgical volumesfor residents. He hopes his greatest success has been the development of the nextgeneration of ophthalmologists and that he has been a positive influence for each ofthem as they “play it forward.” He motivates his graduates to be successful from thestart of their careers, to adapt to a changing world, and to be leaders of change. Hestrives to help each resident to reach their fullest potential.Congratulations to Dr. Blomquist! The presentation of the Straatsma Award took placeduring the Program Director Forum of the 2018 AAO annual meeting in Chicago.American Medical Association:Lyle Thorstenson, MD has been re-appointed to the board of directors of theAMA’s Political Action Committee for a two-year term beginning Dec. 1. He, alongwith Michelle Berger, MD, also serves as a Texas delegate to the AMA House ofDelegates.AAO Leadership Development ProgramSince 1998, the Academy’s Leadership Development Program has helped identifyand develop future leaders of state, subspecialty and specialized interest societies.During the one-year program, class participants learn about leadership, advocacy andassociation governance.Congratulations to Gary Legault, MD who graduated from the AAO LeadershipDevelopment Program in fall 2018. He was sponsored by the Society of MilitaryOphthalmologists. Each participant must complete a project; the title of Dr. Legault’sproject was “Society of Military Ophthalmology Website Design and Implementation.”Representing Texas now is Jeremiah Brown, Jr., MS, MD who was inducted into theLeadership Development Program Class of 2019. He is sponsored by OMIC.PAGE 6

Texas’ Own Making Strides with LDP in AfricaSidney Gicheru, MD, TOA past president and a 2012graduate of the AAO’s Leadership Development Program(LDP), has been instrumental in the formation of anLDP within the African Ophthalmology Council (AOC).He is now the CEO of the AOC. Read his recent update:The African Ophthalmology Council (AOC) isthe supranational organization that representsophthalmologists in Sub-Saharan Africa. We started aLeadership Development Program in August 2015.I serve as Program Director for the joint Anglophone and Lusophone programand Mike Brennan (LDP Faculty) serves as Program Director for theFrancophone program. The candidates come from a wide range of Africancountries. Our goal is to create better leaders so national ophthalmologysocieties of Africa can shepherd the use of scarce resources more effectively.On November 1, 2018, I was appointed the CEO of AOC. Our goal is to is todevelop the organizational structure and overall performance of the AOC whileenriching the member experience by expanding programming in addition tothe AOC LDP.The first Anglophone LDP class (AOC LDP I) started in August 2015 inKenya, met in Tanzania in 2016 and graduated in Uganda in 2017. An AOCLDP 1 graduate is taking it a step further. Feyi Grace Adepoju (AOC LDPI) of Nigeria is the AOC representative in the Academy’s LDP XXI, Class of2019. Feyi is the first AAO LDP participant from Africa. We started Class 2in Uganda and held our second session in Addis Ababa, Ethiopia on August28-29, 2018. The Addis Ababa session was our best yet. Some of our AOC LDPI graduates are serving as faculty and will surely be future leaders of the AOC.Following our meeting in Addis Ababa, our faculty and some members ofAOC LDP I & II, flewto Cape Town, SouthAfrica to run an Advocacyand OrganizationalDevelopment course at theInternational PediatricOphthalmology andStrabismus Congress’ROP Africa meeting, onSeptember 3-4, 2018.This AOC LDP projecthas been a labor of lovesince 2015 and we aregaining traction. We wouldnot be able to run this course without the help of International Council ofOphthalmology (ICO) and AAO doctors who have volunteered as faculty. I hopemore global LDP participants have a chance to visit Africa and encourage thosewinterested to join me at the World Ophthalmology Congress (WOC) 2020 inCapetown, South Africa on June 26-29, 2019.Interested inLDP?TOA may nominate anophthalmologist to participate innext year’s LDP class. This is ahighly competitive program. Thenomination includes a promiseof financial support. Each classmeets in person four times, twicein conjunction with the Academyannual meeting. Participantsconclude their time in the programby completing a project in one of10 key areas. If you are interestedin being nominated, contact TOApresident Sanjiv Kumar, MD atpresident@TexasEyes.org byFebruary 1.TOA graduates of the LDPinclude: Dawn C Buckingham, MD(TOA past president) Garvin H Davis, MD Sidney K Gicheru, MD(TOA past president) Todd M Hovis, MD Gary L Legault, MD Helen Ka-Fun Li, MD Aaron M Miller, MD, MBA Ann Ranelle, DO John W Shore, MDPAGE 7

Legal UpdateWhat is Fee Splitting and Why Should You Care?By Andrea Schwab, JD, CPA, TOA General Counselandrea@aschwablaw.comMember Benefit:Submit your questionsregarding TexasRegulatory Laws &Practice Acts toandrea@aschwablaw.comThe Merriam Webster Dictionary defines fee splitting as “payment by aspecialist (such as a doctor or a lawyer) of a part of his or her fee to the personwho made the referral.” Although referral incentives are a common businesspractice in other industries, in medicine they erode the fiduciary relationship,potentially elevating a physician’s financial interests above the needs of thepatient. The American Academy of Family Physicians defines fee-splitting asany division of fees without the full knowledge of the patient and with the intentof influencing the choice of physician, consultant, assistant, or treatment on anyother basis than that of the greatest good of the patient.Fee Splitting is often used interchangeably with the term “kickback” inreference to “anti-kickback/fee splitting,” which occurs when a licensedphysician either pays, or is paid, for the referral of patients. It could also be inthe form of sharing reimbursement fees for services or devices with any personor entity. This type of arrangement would potentially violate federal laws(Stark and federal anti-kickback law) and state laws, as well as medical ethicsguidelines.The federal Anti-Kickback Statute prohibits knowing and willful offers,payments, solicitations, or remunerations to induce referrals of services coveredby Medicare, Medicaid, and other federally funded programs. Likewise, theStark Law prohibits referring Medicare patients for designated health servicesto an entity with which the physician (or an immediate family member) has afinancial relationship, unless an exception applies. See 42 U.S.C. §1320a-7b(b)and 42 U.S.C. §1395nn. The Anti-Kickback Statute is complex in large partbecause of its safe harbors. Although there was a point in which there wassome protection for co-management arrangements (Medicare had implementeda global fee for cataract surgery in the early 1990s), the Office of the InspectorGeneral (OIG) removed the safe harbor on co-management in November 1999.Such a global fee was inherently fee-splitting.Therefore, any co-management arrangement should be carefully conducted asto not violate the federal Anti-Kickback Statute.In addition to federal fee splitting laws, Texas law has an analogous criminalprovision. This state law is often referred to as Texas’ Stark Law, as it regulatesphysician referrals at the state level. The Texas Patient Solicitation Act (TPSA)is a state law that is similar in wording to the federal anti-kickback statute. Itstates that a person commits an offense if the person knowingly offers to payor agrees to accept, directly or indirectly, overtly or covertly any remunerationin cash or in kind to or from another for securing or soliciting a patient orpatronage for or from a person licensed, certified, or registered by a state healthcare regulatory agency. Tex. Bus. & Occ. Code §102.001 et seq. Furthermore,section 102.051 makes soliciting patients an offense, as follows:PAGE 8

“A person commits an offense if the person: (1) practices the art of healing with orwithout the use of medicine; and (2) employs or agrees to employ, pays or promisesto pay, or rewards or promises to reward another for soliciting or securing a patientor patronage.” Tex. Bus. & Occ. Code §102.051(a). “A person commits an offense ifthe person accepts or agrees to accept anything of value for soliciting or securing apatient or patronage for a person who practices the art of healing with or withoutthe use of medicine . a person who practices the art of healing includes anoptometrist.” Tex. Bus. & Occ. Code §102.051(b) and (d). Although section 102.051does not apply to physicians, it applies to optometrists who accept anything of valuefor soliciting a patient.In additional to potentially violating federal and state laws, sharing of fees oraccepting or paying for referral of patients would violate medical ethics. The AMACode of Medical Ethics Opinion 11.3.4 states that payment by or to a physicianor health care institution solely for referral of a patient is fee splitting and isunethical. The Texas Medical Association’s Board of Councilors also condemns feesplitting: payment by or to a physician for the referral of a patient is fee splittingand is improper.What About Co-Management?True co-management is not fee splitting. In a co-management scenario, thepatient pays the physician for the physician’s services, and the patient pays anyother provider such as an optometrist or physical therapist for those services. Comanagement at its core is a series of referrals and stand-alone payment situations.Stand-alone payment situations without the sharing or reimbursement of paymentsis likely not “fee splitting.”There is no circumstance where a physician should give payment directly toanother provider for patient services. Any inducement for referrals or fee splittingwould most likely be deemed an illegal and unethical act.For instance, if co-management of cataract surgery with an optometrist is necessarydue to the patient’s circumstance, the patient will pay the surgeon for the surgeryand will pay the optometrist for their portion of post-surgical care. There is no needor justification for the optometrist to receive any payment for anything other thanthe optometrist’s care—the optometrist should not be receiving a portion of thephysician’s surgery or any portion of the cost of surgery, such as the cost of a deviceor premium lens. This would most likely be considered a referral inducement, feesplitting, or a kickback.A full copy of the AAO’s Comprehensive Guidelines for the Co-Management ofOphthalmic Postoperative Care with citations can be found at www.TexasEyes.org/guidelines-and-forms. TOA was one of the many co-signatory organizations to theseguidelines in 2016.In summary, due to these legal and ethical considerations, both parties are at riskwhen engaging in fee splitting and/or referral inducements. Referrals should bebased on the needs of the patient alone.False Advertisingin YourCommunity?We occasionally hearfrom members whoobserve instances offalse advertising ormisrepresentation of healthcare providers in localpublications. An exampleof this would be a midlevel provider listed as aphysician or surgeon in anewspaper or phone book.While these listings mightbe accidental, it is importantthat members of the publicsee accurate informationabout the various providersin their community.TOA can communicatewith the involved partiesso that you don’t have to.We will explain the lawregarding professionalidentification, specificallythe requirements ofChapter 104 Healing ArtPractitioners, under Title3 Health Professions of theOccupations Code, and theTexas Medical Act.Contact Rachael Reed in theexecutive office atexec@TexasEyes.org orat (512) 370-1518for more informationBecause federal and state anti-kickback laws carry heaving fines and penalties,any physicians involved in referral arrangements should seek the advice of theirprivately retained legal counsel.PAGE 9

Coding UpdateContinued from page 1New J Code J2787Photrex - Riboflavin for corneal crosslinking up to 3cc Riboflavin 5 – phosphate. Didany of you see the poster at AAO describing oral Riboflavin and exposure to naturalsunlight 30 minutes/day for one month seemed to produce equal corneal results toexpensive commercial crosslinking?New Category III CodesEYE-PACEndorsementResultsYour EYE-PAC scoredwell on election night lastNovember, with 95% ofits endorsed candidateswinning. Sadly, somefriends of medicine willnot be returning to theTexas Legislature, but wehave new opportunities toeducate freshmen on qualityeye care. If you have arelationship with any newlegislators, please let usknow as you could be a keycontact.0509T - Electroretinography (ERG) with interpretation and report, pattern (PERG).This has been created specifically for appropriate coding and tracking of this newertechnology; there was inadequate literature support for Category 1. There aresignificant differences from the historical ERG code. The coverage and payment aredetermined by the Medicare Contractors. CMS proposed Active Status. The AAOproposal is a work value of 0.40, 10 min Intra Service Time, 12 minutes total time.0506T – Macular pigment optical density measurement by heterochromatic flickerphotometry, unilateral or bilateral, with interpretation and report.0507T – Near infrared dual imaging (ie, simultaneous reflective andtransilluminated light) of meibomian glands, unilateral or bilateral, withinterpretation and report.0514T – Intraoperative visual axis identification using patient fixation (Listseparately in addition to code for primary procedure).Revalued CPT Codes.All of these CMS proposed values have been finalized except for RB Alcohol.*Removal of Foreign Body65205 – Removal of foreign body, external eye; conjunctival superficial ( 36.97) CMS Proposed 2019 wRVU: 0.49 RUC approved wRVU: 0.49 Current wRVU: 0.7165210 – Removal of foreign body, external eye; conjunctival embedded (includesconcretions), subconjunctival, or scleral non-perforating ( 58.07) CMS Proposed 2019 wRVU: 0.61 RUC approved wRVU: 0.75 Current wRVU: 0.84Injections67500 – Retrobulbar injection ( 62) CMS Proposed 2019 wRVU: 1.18 RUC Recommended wRVU: 1.18 Current wRVU: 1.44PAGE 10

*67505 – Retrobulbar injection with alcohol ( 86) CMS Proposed 2019 wRVU: 0.94 RUC Recommended wRVU: 1.18 – Accepted by CMS Current wRVU: 1.2767515 – Injection into Tenon’s Capsule ( 74) Proposed 2019 wRVU: 0.75 RUC Recommended wRVU: 0.84 Current wRVU: 1.40Ophthalmic Ultrasound76514 – Ophthalmic ultrasound, diagnostic; corneal pachymetry, unilateral or bilateral(determination of corneal thickness) ( 13) Proposed 2019 wRVU: 0.14 RUC recommended wRVU: 0.17 Current wRVU: 0.17Medicare Regulatory Reform Agenda ContinuesThe American Academy of Ophthalmology launched a regulatory relief effort in2016 in response to the election outcome. The immediate focus was on relief from2018 performance penalties such as PQRS, EHR Meaningful Use, and Value-BasedModifier. In 2017 the Academy also began a campaign to reduce significant burdens ofprior authorization within Medicare Advantage. These efforts brought simplificationand eased the burden of MIPS for 2018. Specifically, it halted the application of theMIPS bonus and penalties to Part B drug payments to physicians. It also providedCMS flexibility to limit the cost component of MIPS to 10%-30% through the 2022performance year, and it provided for CMS continued flexibility to set an incrementalthreshold to avoid a MIPS penalty through the 2022 performance year.The relief was significant for small practices in 2018. Small practices enjoyed a 5-pointbonus on their MIPS final score, they qualified for interoperability hardships, and theyhad a 3-point floor on quality measures.The recently released Medicare Conditions of Participation proposed rule would giveHOPDs and ASCs flexibility in determining pre-op H&P. If finalized, these policies willbe determined by the facility medical staff.Finally, the Academy won the repeal of the Independent Payment Advisory Board (IPAB).A New Threat: Medicare Advantage Step Therapy GuidanceIn August, the US Department of Health and Human Services (HHS) announcedwithout prior notice a new drug policy for Part B office-administered drugs forMedicare Advantage plans. The policy creates unequal access to Part B drugs forMA plan beneficiaries as compared to Original Medicare and restricts access in away not permitted under Part B. It also rewards beneficiaries for a change in clinicaltreatment decisions that could be harmful to the patient. Several MA plans have alreadyimplemented step therapy for 2019 with insufficient notice to patients.The Academy cont

& TOA Executive Council Meeting Austin (any member may attend) March 4, 2019 TMA First Tuesday Advocacy Day Austin March 29, 2019 Codequest Lubbock March 30, 2019 Codequest Dallas April 2, 2019 TMA First Tuesday Advocacy Day Austin April 6, 2019 Codequest Houston April 10 - 13, 2019 AAO Congressional Advocacy Day and Mid-Year Forum Washington, DC