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Don't Pass Up Pass-Through Payments
Understanding the billing process will ensure your cataract patients have access to new and innovative medications.
Lisa Nijm
Publish Date: April 16, 2020   |  Tags:   Financial Management
INNOVATIVE MEDS Ophthalmic drugs improve patient care, but their pass-through funding status can be cumbersome to navigate.

Ohthalmology has a long history of innovation, and we're fortunate to have access to several cutting-edge treatments that reduce pain and inflammation after cataract procedures, thereby reducing the need for post-op eyedrop therapies.

  • Omidria (1 % phenylephrine and .3 % ketorolac) is an irrigating solution administered with balanced saline solution during surgery to maintain pupil dilation and reduce post-op pain. It costs about $465 per case. Omidria's pass-through status expires on Oct. 1. Lobbying efforts by the product's manufacturer could result in another new pass-through period or establish a permanent separate reimbursement.
  • Dextenza is a corticosteroid insert placed by the surgeon to treat post-operative pain by delivering a tapered dose of dexamethasone for 30 days. It costs approximately $572 per insert with a pass-through status that runs until the end of 2021.
  • Dexycu (dexamethasone) 9% is an extended-release steroid delivered with a single injection that is designed to decrease post-op inflammation. It costs about $696 per case and its pass-through status also runs until the end of 2021.

These medications can decrease the usage of postoperative drops, thereby decreasing the need for patient compliance and improving outcomes.

The significant price of these medications makes them cost-prohibitive in a specialty with slim profit margins, but the pass-through status lets your facility bill Medicare separately for the per-case cost plus 6%.

Congress created pass-through payments to ensure innovative new drugs, devices and biological agents are available for patients and paid for separately from a facility's or physician's bundled payment. While the cost may seem large relative to the facility fee, this is a mere fraction of what CMS has set aside for pass-through products. CMS, not the drug manufacturer, determines the price of these medications through a complex formula that they use for all pass-through products.

If these medications don't obtain approval from CMS when their pass-through statuses expire, they will be considered "packaged" and will no longer be reimbursed separately, likely severely limiting patient access to these innovative medications.

The pot of money that CMS sets aside each year for pass-through payments remains underused.

The pot of money that CMS sets aside each year for pass-through payments remains underused, partly because the process to get reimbursed for the separate payments can be difficult to understand and implement. The perceived difficulty in getting paid separately from the cataract payment bundle has caused some surgeons and facilities to limit their use of these drugs. Fortunately, there are some relatively simple ways to make sure your facility is properly reimbursed and taking advantage of the pot of use-it-or-lose it money that CMS sets aside for these medications each year.

  • Contact billing teams. The makers of all three drugs provide online access to interactive tools that can help you navigate the reimbursement process. They can also connect you with case managers that will work with your facility to incorporate pass-through payments into your revenue stream. The manufacturers' reimbursement teams can also provide information about patient assistance programs for those who qualify.
  • Begin with Medicare B. Products with pass-through statuses have reliable reimbursement processes for these patients. Check whether your non-Medicare Part B payer contracts that are specific to your facility allow for separate payments of pass-through drugs. Consider renegotiating contracts that do not permit pass-through payments.
  • Fine-tune the process. Maintain communication with your surgeons' practices to make sure the pass-through drug will be available for the appropriate patients. To help ensure patients will have coverage for a pass-through product, some physicians' practices flag charts with a sticker and add drop-down alerts in EMRs to remind providers to keep the payment process on track.

Make sure all claims submissions are timely and accurate. If any claim is denied, pursue the appeals process and include a letter of medical necessity in your appeal. Be sure to re-engage the manufacturers' reimbursement team for further help if there are issues while implementing these products.

The effort you make to connect all the dots in this process goes beyond making sure patients have access to innovative therapies. Remember, CMS sets aside the amount of money for innovative-but-expensive products the year before it's paid out. If a high-volume of cardiologists utilize more pass-through payments than ophthalmologists, that may inadvertently limit future innovations that benefit ophthalmic patients. Understanding how these payments work will allow for better patient care without your facility having to foot the bill. That, in turn, will encourage companies to continue their research and development efforts for even more ophthalmologic breakthroughs in years to come. OSM