Medicare Payments to ODs in 2015

How much will ODs make through Medicare in 2015?

In 2015, optometrists will be paid $1.163 billion by Medicare, according to estimates from the Centers for Medicare and Medicaid Services (CMS). This is a slight increase over 2014 when CMS estimated optometrists would be paid 1.116 billion by Medicare.

As in previous years, Medicare payments for certain services will increase while others will decrease.  For the services most frequently reported by optometrists under the Medicare program, the changes in reimbursement from 2014 to 2015 range from an 8 percent decrease to a 3.3 percent increase.  Certain evaluation and management services for all physicians will be reimbursed at a slightly higher rate for 2015.   There are a few notable changes for 2015:

·    3.3 percent increase in the code for dark adaptation eye exam
·    1.3 percent increase in the code for the highest level office visit code for an established patient
·    2.7 percent decrease in the code for removal of a foreign body from the eye
·    8.0 percent decrease in the code for electroretinography

One factor impacting reimbursement for optometrists in 2015 is the CMS identification of an error the agency made in calculating the malpractice relative value units (RVUs) that have been used for ophthalmology and optometry for the past five years.  All procedures are assigned a work, practice expense and malpractice relative value.  The malpractice relative value is developed based on an analysis of the practice liability costs associated with performing a particular service and taking into account the specialties that perform the service.  These factors result in the development of a designated malpractice RVU for each service.  In 2014, CMS indicated that due to an error they made in calculating malpractice RVUs for optometrists and ophthalmologists, the malpractice RVUs for the past four years have been at a level higher than they would have been had they been calculated correctly since 2010.To correct this error, CMS reduced by 1 percent the malpractice RVUs for optometry. The malpractice component accounts for only about 4 percent of the total relative value for each service, so the impact on many services that optometrists provide is relatively low.  Services such as corneal topography, eye examinations with photos and serial tonometry exams have all been reduced by 0.2 percent in 2015 from 2014 rates.  While many codes reported by optometrists reduced in value in 2015, over the past 5 years the values for the majority of services have increased.  For example, the reimbursement for a comprehensive eye exam decreased by 1.6% from 2014 to 2015, however, since 2011 the reimbursement for that service has actually increased 7.1%.

The rise of Medicare OD payments

Despite changes for 2015, Medicare payments to optometrists have grown steadily over the past 10 years. In 2005, CMS estimated that optometrists would earn 666 million in Medicare payments.  With Medicare payments to optometrists reaching over 1 billion dollars in 2015, over the past 10 years Medicare payments to optometrists has increased approximately 75%.  In the same time period, Medicare payments to ophthalmologists increased approximately 24%.  "Fighting to safeguard our physician status in Medicare and ensuring that ODs and our patients are treated fairly is a basic AOA member benefit.  The 75% increase in payments over the last decade demonstrates how successful we've been in educating policymakers and eliminating barriers," says AOA President David A. Cockrell, O.D.  Through engagement with the American Medical Association/Specialty Society Relative Value Scale Update Committee (RUC) and AOA's regulatory advocacy, the AOA works to make valuations for eye care accurate.  However, a critical point to remember is that the Medicare physician payment system is ultimately budget neutral. Therefore, if there are increases to valuation for one service, the valuation of other services will decrease.

Future SGR Impact

One major factor that will impact Medicare reimbursement in 2015 is the Sustainable Growth Rate (SGR) formula.  Unless Congress acts before April 1, ODs and other physicians will face a roughly 21 percent Medicare pay cut.  AOA is calling on optometrists to help us work with Congress to fix the broken payment system.     

For more information contact Kara Webb at kcwebb@aoa.org