"" 
OPHTHALMOLOGVOPTOMETRY

RELATIONSHIPS INVOLVED 
CATARACT SURGERY

+t- l/ 
" SIIlYICls.

""Ia 
OFFICE OF INSPECTOR GENERAL 
OFFICE OF ANALYSIS AND INSPECTIONS 
APRIL 1989  PHTHALMOLOGVO PTO  ETRY

RELATIONSHIPS INVOLVED 
CATARACT SURGERY

RICHARD P. KUSSEROW 
INSPECTOR GENERAL 
o AI-07 -88-00460  APRIL 1989  EXECUTIVE SUMMARY 
OBJECTIVES 
This inspection focuses on issues involving optometrsts ' providing postoperative care to 
catat 
Medicare beneficiares following  surgery. The overall objectives of the inspection 
were to detennne: 
the extent and frequency of postoperative care by optometrsts; 
the extent of referral arangements between ophthalmologists and optometrsts; 
the manner of billng by ophthalmologists and optometrsts for cataract surgery when an 
optometrst provides postoperative car; and 
whether the practice of optometrsts ' providing cataract surgery postoperative care could 
lead to abusive referral arrangements, and possible duplicate bilings. 
BACKGROUND 
This program inspection was requested by the Administrtor of the Health Care Financing Ad
ministration (HCFA), who was concerned about the issue of optometrsts ' providing postopera
tive care to Medicare beneficiares who had cataract surgery. This practice increased after 
Medicare coverage was expanded by the Omnibus Budget Reconciliation Act of 1986. This 
legislation penntted coverage of optometrsts as physicians for any services they ar legally 
authorized to perform in the State in which they practice. All 50 States permit optometrsts to 
use diagnostic drgs. Funher, 23 States have passed legislation allowing optometrsts to use 
and prescribe therapeutic drugs, greatly expanding their scope of practice and ability to treat 
patients during the postoperative period following cataract surgery. 
METHODOLOGY 
Preinspection work included meetings and contacts with the Americ  n Academy of Ophthal
mology, the American Optometrc Association, State licensing boards, Medicare carrers, and 
HCFA staf. 
A random sample of eight Medicar carers was selected. Two carrers, who were randomly 
selected twice, provided two independent samples. One hundred claims "histories " for 
patients who had undergone cat8ract surgery were randomly selected for review from each 
sampled carer (200 from those carers which provided two samples). These histories were 
analyzed to determine the extent to which ophthalmologists delegate postoperative care to op
tometrsts, and the extent to which optometrsts are reimbursed for postoperative care already  biled by the ophthalmologists as pan of a global fee coverig both surgery and postoperative 
care. 
The eight carers also provided a separate sample of the names of 60 ophthalmologists who 
perform catarct surgery for Medicare beneficiares. One-half of these surgeons were selected 
from among the highest-paid ophthalmologists at each carer and the other half from those 
receiving the mid-range of payments. Fifty-eight of the 60 surgeons were interviewed regard
ing their practice. The surgeons were requested to provide a sample of names of optometrsts 
handling aftercar, and a sample of names of cataract surgery patients. The optometrsts and 
patients were interviewed to obtain their opinions on the issues of optometrsts ' providing 
cataract surgery referrals to ophthalmologists and optometrsts ' providing postoperative care. 
In addition, peer review organizations (PROs) and State Boards of Optometr were contacted 
in each of the sampled States to discuss their experiences and opinions regarding these issues. 
FINDINGS 
Medicare May Be Paying Too Much For Postoperative Care Following Cataract Surgery 
The number of postoperative days encompassed by the global fee vares by carrer, as 
does the percentage of the global fee allocated to surgery versus postoperative care. 
a result, in some cases Medicare is makng additional payments for postoperative care 
which would be included in the global fee by other carers. 
In 97 percent of cataract surgery cases reviewed, the ophthalmologists 
biled a global 
number of these cases, optometrsts were paid inappropriately by 
fee. In a small 
Medicare for postoperative services during the period encompassed by the global fee. 
There Is A Direct Correlation Between The Existence Of Referral Arrangements, Formal 
And Informal, And The Use Of Optometrists For Follow-up Care 
Thireen (46 percent) of the highest-paid ophthalmologists sampled referred cataract 
surgery patients to optometrsts for postoperative care, in contrst to 3 (10 percent) of 
the ophthalmologists receiving mid-range payments. 
Ophthalmologists who refer cataract surgery patients to optometrsts for postoperative 
care receive a higher percentage of their surgical referrals from 
optometrsts than do 
ophthalmologists who do all postoperative care themselves (32 percent versus 7 
percent). States that allow optometrsts to prescribe therapeutic drugs had a higher 
overall percentage of optometrc referrals.  The Inspection Did Not Examine Quality Of Care; However, Some Potentil Vulnerabilities 
Were Noted 
There is no consensus regardig the division of responsibilty following cataract surgery 
when the surgeon does not provide all such care. This lack of standards for treatment 
means that there ar no standards for review of such car. 
Ophthalmologists who refer their patients to optometrsts for postoperative care, 
compared to those who perform their own postoperative care, generally follow their 
patients for a shorter postoperative period. However, most optometrsts said that 
although they provide postoperative care, they only treat routine complaints, and would 
refer patients back to ophthalmologists for treatment of serious complications. 
More than half the ophthalmologists stated they had provided Medicare patients with 
second opinions regarding the necessity for cataract surgery. However, only 20 percent 
of the sample patients said they had received a second opinion before undergoing 
surgery . 
RECOMMENDA TIONS 
To Improve Medicare Payments For Cataract Surgery 
The HCF A should develop national guidelines covering the number of postoperative 
days included in a global fee for cataract surgery, and the percentage allocation of a 
global fee to surgery and postoperative care. 
The HCF A should require all carers to instrct optometrsts and ophthalmologists in 
the use of procedure code modifiers, and to establish screens for duplicate 
billng within 
the global-fee period. The HCFA should also identify ophthalmologists most likely to 
refer cataract surgery patients to optometrsts for postoperative care. Such referrals 
would provide for a focused postpayment review of cataract surgery patient records to 
insure appropriate bilings.

To address referral arrangements that may violate the anti-kickback provisions 
The HCFA should require carrers to refer any potentially abusive arrngements 
between ophthalmologists and optometrsts, which the carrer identifies, to the Office of 
Inspector General for investigation. 
To Improve Quality Of Care For Cataract Surgery Patients 
The HCF A should require PROs, including local ophthalmologists, to work with their 
State Boards of Optometry to establish protocols for postoperative cataract surgical care.  Such protocols should addrss the minimum number and frequency of postoperative 
visits, the necessity for 24-hour avmlabilty of emergency care, and the presence of 
wrtten agreements between referrg practitioners regarding the division of 
become pan of the PROs ' review of cataract 
responsibilties. These protocols should 
surgery in both inpatient and ambulary settings. 
The HCFA should require mandatory seond surgical opinions for elective surgeries, 
such as cataract surgery, paid under Medcare. 
COMMENTS 
The HCFA agreed with the recommendations with the exception of a second surgical opinion 
for cataact surgery. We continue to believe that the requirement of a second opinion for 
is essential, parcularly when this surgery is generally performed in other 
catarct surgeries 
than an acute care facilty. 
The OIG issued the draft inspection repon on "Ophthalmology/Optometr Relationships In
volved in Cataract Surgery" for comments to the American Academy of Ophthalmology and 
the American Optometrc Association. Neither organization disagreed strongly with the find
ings. Their comments presented their opposing positions regarding the use of optometrsts 
provide postoperative care. 
The complete text of the comments by HCFA and the Academy and Association are included 
in appendix III.  . .  ....  ................ ............  .............. . .....  .................... ... ...... ............ .......... ...... ............ . .................... ...... ................ ....... ............. . .... ....... . ........ ........ ........ . 
.......... ...... ........... ...... ............. .. ......  ....... ........ ..... .......... ........  
TABLE OF CONTENTS

PAGE 
EXECUTIVE SUMMARY 
............ ......... .........................0 II.... ..... II. 11..

NTRODU CTJ ON 
... ..0... II..... ..11.... .11.... 
o BJ ECTIVES 
BACK G RO  UN D.  ..11... ......... .11... .... 
DOLOG Y 
M ETHO  ... ... II  ........... II..... ........... .11. 
FI N DI 
 N GS  It II O. IIe.II... .11.110 811.8.
RECOMMENDATIONS AND AGENCY COMMENTS ...........................

APPENDIX I 
OPHTHALMOLOGY IOPTOMETRV SAMPLE ................................

APPENDIX II 
OPHTHALMOLOGISTS COMPARISON DATA ...............................

APPENDIX II 
COMMENTS BY THE HEALTH CARE FINANCING 
ADMINISTRATION, AMERICAN ACADEMY OF 
OPHTHALMOLOGY, AND AMERICAN OPTOMETRIC 
II....... .... ..... .... ..... ..... .. 
ASSOCI A TION.. 
 .11..1111110".. e ClII.. eo.o.o 000 II 0 0 .
 INTRODUCTION

OBJECTIVES 
This inspection focuses on issues involving postoperative care rendered by optometrsts to 
Medicare beneficiares following cataract surgery. The overall objectives of the inspection 
were to determne: 
the extent and frequency of postoperative care by optometrsts; 
the extent of referral arangements between ophthalmologists and optometrsts; 
the manner of biling by ophthalmologists for cataract surgery when an optometrst 
performs postoperative care; and 
whether the practice of optometrsts ' providing cataract surgery postoperative care could 
lead to abusive referral arangements, and possible duplicate bilings. 
BACKGROUND 
This program inspection was requested by the Administrator of the Health Care Financing Ad
ministration (HCFA) who was concerned about ophthalmologists ' referrng cataract patients to 
optometrsts for postoperative care after performing cataract surgery. The concern stemmed 
from a statement by the American Academy of Ophthalmology regarding adherence to profes
sional ethical standards. According to the Academy, operating surgeons are responsible for 
providing postoperative care to their patients. Funher, surgeons who turn over their respon
sibility for postoperative care to someone else do not fulfill their responsibilties to the patient. 
In addition, the bylaws of the American College of Surgeons state that it is unethical to turn 
over postoperative care of a patient to another physician who is not as well qualified to under
take it. Their concern is that the quality of postoperative car provided by someone other than 
the surgeon may be poor and result in placing the patient at greater risk. 

Nature of Surgery 
Cataracts of the eye occur when the natural crystallne lens inside the eye becomes cloudy. 
Cataracts can occur at any age, but are more prevalent in the elderly population. Due to the 
aging process, the natural lens becomes hard and unable to focus. This progressive process 
may eventually result in blurred vision or even blindness. Surgery is the only effective way to 
remove a cataract. Vision can be restored after the natural lens of the eye is removed and a 
permanent intraocular lens (IOL) is implanted inside the eye. Cataact glasses or contact len
ses are used for candidates not suitable for IOL implants, although even those with an IOL im
plant usually require eyeglasses for reading, sewing, or other activities.  Due to technological advances over the last 10 years, cataract surgery is highly successful; the 
patient s vision can be restored in up to 90 percent of all cataract cases. However, according 
to medical studies, increasing patient age, surgical problems, postoperative complications, and 
adverse reactions are among the factors which could reduce visual acuity after cataract 
surgery. It is estimated that medical complications following cataract surgery may occur in 
about 3 to 5 percent of the cases but would not necessarly result in a loss of vision if recog
nized and treated properly. The postoperative recovery period usually lasts 6 to 12 weeks, 
during which time the eye heals and visual rehabiltation takes place. 
Medicare Coverage

Under Medicare, vision care services are limited to those necessar to treat eye diseases such 
well as preoperative and postoperative care, are covered by 
as catarcts. Cataract surgery, as 
Medicare when medically necessar. Cataract surgery is considered major eye surgery with a 
potential for complications and is one of the most frequently performed procedures in the 
Medicare population. Over one millon cataract surgeries were performed in 1987, with more 
than $1 bilion paid to surgeons.

Cataract surgical care for Medicare beneficiares is covered by a global fee that includes 
surgery and postoperative care. The Medicare  fee period using 
carrer establishes the global-
criteria developed from medical practice in the carrer s service area. The surgeon provides all 
the services during the global-fee period, e. g. 90 days, when a global fee is biled. When the 
surgeon provides some of the services, e.g. surgery only, and the postoperative care is 
provided by another physician, the two-digit modifier " 54" should be used on the bil to indi
cate surgical care only. When only postoperative care is provided, the modifier "55" should 
be used to show postoperative management only. Carers are required to screen bils for eye 
fee period to avoid inappropriate or duplicate payments. 
care services within the global-
In 1980, the Omnibus Reconciliation Act authorized Medicare payments to optometrsts for 
services related to catarct surgery (Section 937 of Public Law 96-499). Until March 31 
1987, optometrsts were covered by Medicare for examination services related to aphakia (the 
absence of the natural lens in the eye). Optometrists could only bil Medicare for determining 
visual acuity, prescribing glasses, and dispensing optical devices to patients who had had 
cataracts removed, although the State may have allowed them to perform a wider range of ser-
VIces. 
, 1987, Medicare coverage of optometrsts ' services was expanded with Sec
Effective April 1 
tion 9336 of Public Law 99-509 (the Omnibus Budget Reconciliation Act.of 1ge6, known as 
OBRA 86). This expansion allowed Medicare coverage of optometrists as physicians (as 
defined in the Social Security Act governing Medicare) in providing cataract surgery pos
toperative care, within the legal authorizarions of the States in which they practice. However 
this expansion of coverage raises questions about the division of responsibility between the 
ophthalmologists and optometrsts regarding appropriate patient care and biling to the 
Medicare program.
 Licensure Issues 
There is no uniform set of optometrc services covered by Medicare, since State licensure laws 
vary widely. Qualifications, training requirements, and the scope of practice for optometrsts 
are established under State law. In this regar, 50 States permit optometrsts to use diagnostic 
drgs. Twenty-three of the States also permt optometrsts to prescribe therapeutic phar
maceutical agents, which significantly expands the optometrc scope of practice and the ability 
to treat some postoperative complications. Postoperative cataact care was within the scope of 
practice of an optometrst in the seven States included in the inspection sample. All seven 
States permt optometrsts to use diagnostic drgs, and three of the seven also allow the use of 
therapeutic drgs. 
OIG Concerns 
The Office of Inspector General (OIG) is concerned with situations in which abusive referral 
arangements result in Medicare overpayments and kickbacks. Postoperative care by someone 
other than the surgeon raises concerns over global reimbursement to surgeons who perform 
only cataract surgery and not postoperative care. In addition, patient referrals between op
tometrsts and ophthalmologists (so-called networking) could result in improper payments. 
The 010 has identified potential vulnerabilities, including coercion to refer patients and 
failure to adequately provide preoperative and postoperative care. Instances of these potential 
vulnerabilities have been identified in complaints to the OIG and/or to the Senate Select Com
mittee on Aging. 
METHODOLOGY 
A sample of Medicare carers was -selected at random proponional to size (in terms of num
bers of IOL surgeries in 1985). Two carers were randomly selected twice and provided two 
independent samples. Selected carers processed claims for beneficiares in Nortern and 
Southern Calfornia, Louisiana, Montana, Western Missouri, Upper New York State, North 
Carolina, and Oregon. (See appendix I.) Each carer was requested to identify all 
beneficiares who received one of four specified cataract services during the period April I 
1987 through March 31 , 1988. Each carrer then provided beneficiar payment histories for a 
random sample of 100 of the identified beneficiaries (200 for those carers which provided 
two samples). The total sample of 1 000 beneficiaries who had cataract surgery represented 
062 procedures, since some beneficiaries received surgery on both eyes. 
In addition, the eight carrers provided the OIG with the names of a sample of three (six at two 
carrers) ophthalmologists from each of two groups: (1) those who received the highest 
Medicare payments in that specialty; and (2) those who were paid in the mid-range of pay
ments during fiscal year 1987. Of the 60 names of ophthalmologists provided by the carriers, 
58 were contacted. We were unable to contact the remaining two. 
The ophthalmologists we talked to provided us with the names of 49 patients who had 
received. cataract surgery. Those who refer their cataract surgery patients to optometrists for  postoperative care also provided us with the names of 28 of these optometrsts. 
The ophthalmologists, optOInetrsts, and patients were contacted in person or by phone and in
terviewed using discussion guides. Opinions were obtained regarding the issue of 
optometrsts ' providing referrals and postoperative care following cataract surgery, second 
opinions for cataract surgery, and the effect of cataract surgery on the patient s life. 
Peer review organizations (PROs) and the State Boards of Optometr were contacted in each 
of the sampled States. The organizations were queried on the extent of postoperative care by 
optometrsts after cataact surgery in their States, and whether they were aware of positive or 
negative outcomes of this practice.  FINDINGS

Medicare May Be Paying Too Much For Postoperative Care Following Cataract Surgery 
A. Variance In Postoperative Days and Global Fees 
There are no specific HCFA guidelines regarding: 
the number of postoperative days covered by a global fee; and 
the percentage or amount of the global fee allocated for the surgery and postoperative 
care. 
This leads to nationwide varances in postoperative days covered by Medicare and in the 
amounts allocated to surgery and postoperative care. Through our contacts with the eight 
Medicare carers included in this inspection, we found that the global fee covered postopera
tive periods ranging from 10 to 120 days, with a median of 90 days. 
We asked the 58 ophthalmologists their opinions about the appropriate length of the postopera
tive period of recovery following cataract surgery. The median number of postoperative days 
identified in these interviews was 86, ranging from 10 to 365 days. 
Where the carer s global-fee postoperative period is 10 days, both ophthalmologists and op
tometrsts can begin biling for services rendere on the 11 th day, 1 day following the end of 
the carer-established global-fee postoperative period. This very shon global-fee postopera
tive period allows additional program payments. These payments could be avoided if national 
guidelines on the number of postoperative days in a global fee were developed which included 
a greater number of days in the postoperative period. 
We also found the portion of the global fee allocated for postoperative care varied among car
carers utilized a 70/30 global-fee split between the surgical procedure 
riers. Three of the 8 
(70 percent) and postoperative care (30 percent). Other carrers based Postoperative alloca
tions on specific procedure codes, made adjustments after a review of the charges, or used no 
modifier or global-fee split at all. 
B. Optometry Services Biled During the Global-Fee Period 
Ophthalmologists biled Medicare a global fee for cataract surgery in over 97 percent of the 
L062 cataraci. surgery cases reviewed. The global fee covers both the surgical procedure and 
postoperative care. In 25 of the cases covered by a global fee, optometrists also biled 
Medicare. In 10 of these cases, the services provided by the optometrists were outside the 
global-fee period. However, in the remaining 15 cases, the services were perfonned within 
the global-fee period. These services represent a potential overpayment of $826 because car
riers did not deny these services even though a global fee was biled by the ophthalmologists. 
The HCFA requires that Medicare carrers establish a screening mechanism that wil allow for 
identification of inappropriate or duplicate services.  There Is A Direct Correlation Between The Existence Of Referral Arrangements, Formal 
And Informal, And The Use Of Optometrists For Follow-up Care 
A. Optometric Referrals For Cataract Surgery
The inspection found that 13 or 46 percent of the highest-paid ophthalmologists sampled 
allow optometrsts to provide postoperative car to their cataract surgery patients, in contrast 
to 3 or 10 percent of those in the mid-range of payments. We also found that sampled ophthal
mologists who allowed optometrsts to provide their cataract surgery patients with postopera
tive care received 32 percent of their cataact surgery patients through referrals from 
who did not refer their patients to optometrsts for postopera
optometrsts. Ophthalmologists 
tive care received only 7 percent of their cataract surgery referrals from optometrsts. 
F!qure 1

COMPARISON OF' OPHTHOI.OGIS1 WHO 00 Use: OPTOMETISTS WITH 
THOSE WIO DO Nor USE OPTOMETRISRTSE FOiRR PROSATOP ERTIVE CAE 
BY SOURCES OF 
L.QOID 
DO USE

00 NOT USe: 
IS' 
OPTOM 
OWN PATIENT 
t5 WORD OF MOUTH

OTHE= PHYSICIAS 
10  :1 0(
ZO 
P!:CENTAGE: 
(re) 
FIGURE AR 
 ElENIIES :1) 
We identified two examples of contractual agreements between ophthalmologists and op
tOmetrsts. The first involved an employment agreement between an ophthalmologist and op
tOmetrst. It was determined by Offce of General Counsel to represent a bona-fide 
employment contract, exempt from criminality under the law. The second involved a' lease ar
rangement. It was not developed by the Office of Investigations because of the minimal pay
ments involved. 
The average percentage of optometrc referrals to the sampled ophthalmologists varied by 
State, ranging from 5 to 28 percent. The highest percentages of optometric referrals occurred 
in those States that permit optometrsts to provide therapeutic drugs.  Fiaure 2

PERCENTAGE OF REFERRALS

FROM OPTOMETRISTS 
8Y STATE

2ft 
= '5 
5 . 
CA LA MO MT NC NY 

STATes TI-"A.T AL.!.OW T  !:RAF'e:UTIC ORUCS 
STATES THAT CO NOT ALL'  W THERAPEUTIC DRUGS 
B. Postoperative Care by Optometrists
An examination ' of three sources of data revealed that: 
sixteen of 58 ophthalmologists interviewed (nearly 28 percent) allow optometrsts to 
provide postoperative car to their cataract surgery patients; 
in 15 of 1062 cases reviewed, payments were made inappropriately for postoperative 
care that should have been denied, because the surgeon had already been paid a global 
fee (without moifers) that includes postoperative care; and 
eighteen of 49 patients interviewed (nearly 37 percent) stated they saw a doctor other 
than the surgeon for postoperative care. In some instances the patients were not certain 
if the doctor was an ophthalmologist or an optometrst. 
A comparson of data between the 16 ophthalmologists who allow optometrsts to provide pos
toperative care and the 42 who do not is shown in appendix II. 
Ophthalmologists reported the major reason patients returned to an optometrst for postopera
tive care was the distance involved in traveling back to the operating surgeon. Optometrists 
stated that patients preferred to return to their local physician for care; this was confirmed by  almost half of the patients who received cataract surgery. They stated that travel was required 
to receive cataract surgery since it was not available in their communities. 
All 28 optometrsts interviewed stated they provide cataract surgery postoperative care, and 
feel confident in monitoring these patients for the detection of complications that would re
quire the patients ' return to the ophthalmologist. However, 17 (61 percent) said they only 
treat routine complaints and complications such as blurred vision, redness of the eye, and a 
slight increase in intraocular pressure. Thirteen of the 17 are in States that allow optometrsts 
to provide therapeutic drgs to treat eye conditions, but only 1 of the 13 said he would attempt 
treating a serious complication, and then only after conferrng with the operating ophthal
mologist. The remaining 11 would provide only routine eye exams and refractions, and 
monitor the eye for increases in pressure and other indications of complications. These 11 op
tometrsts indicated that patients with any indication of a complication would be referred back 
to the ophthalmologist for treatment. 
The ophthalmologists interviewed were significantly divided on the issue of optometrsts 
providing cataact surgery postoperative care. We found that the majority (42) of those oph
thalmologists interviewed believed that optometrsts are not qualified to provide postoperative 
care. A minority of (16) ophthalmologists interviewed approve of optometrsts providing their 
patients with postoperative care. The majority also stated that the services provided by an op
tometrst durig postoperative care are not as comprehensive as the services provided by an 
ophthalmologist. 
The Inspection Did Not Examine Quality Of Care; However, Some Potential Vulnerabilties 
Were Noted 
A. Potential Causes of Poor Quality Care 
While a medical peer review of patient records was not performed, interviews with sampled 
ophthalmologists indicated the following potential vulnerabilities in cases where an op
tometrst would provide the follow-up care to cataract surgery. 
Twelve percent of the ophthalmologists do not always examine the patient prior to the 
date of surgery. 
Twelve percent of the ophthalmologists do not always examine the patient the day after 
surgery. 
Ophthalmologists who refer their patients to optometrsts for postoperative care, 
compared to those who perform their own postoperative care, were found to follow their 
patients for a shoner postoperative period. 
Our review did not find an existing national professional standard for cataract surgery follow-
up care provided by an optometrist. In the absence of a standard for treatment, "sub-standard"  care cannot be identified durng peer review with the degree of precision possible when 
reviewing postoperative care rendere by the surgeon. 
Most optometrsts interviewed said ifuat :a1though they provide postoperative care, they only 
treat routine complaints, and would rrefer :patients with evidence of a serious complication 
This, however, does not constitute a standard for care, 
back to ophthalmologists for tratment. 
and may place patients at risk if a ra-e sUTgica complication is not identified by an optometrst. 
B. Second Opinion For Catarac Slrgery 
The physicians interviewed stated that second opinions were requested as a requirement for 
private insurance. Thiny of 58.ophtha111oi,ogists (52 percent) stated they received requests for 
second opinions, and 11 of 28 of the optometrsts (39 percent) said they had provided 
Medicare patients with second opinions regading cataact surgery. Ten of the 49 Medicare 
patients (20 percent) we interviewed stated thy sought a second opinion before undergoing 
sou:glt:a seond opinion from an ophthalmologist, and 
cataract surgery. Six of the 10 patients 
send 
the remaining 4 saw an optometrst for the . opinion. This study did not attempt 
determine the medical necessity of the 1,061 :surgeries reviewed. However, cataracts develop 
slowly, and surgery may be avoided for ma'RY yeas if the patient so desires. Additionally, 
cataract surgery should not be performed UIi ess eyesight is expected to improve. 
The OIG has previously recommended that legislation be adopted to require a mandatory 
second opinion program for elective surgeries for Medicare patients.  RECOMMENDATIONS AND AGENCY COMMENTS 
RECOMMENDATION 
The HCFA should develop national guidelines covering the number of.postoperative days 
(e.  , 60 to 90 days) that should be included in global fees, and the percentage allocation of 
global fees to surgery and postoperative care (e. g., 80/20). These guidelines should allow suf
ficient postoperative time to complete all necessar postoperative exams and procedures, with 
the exception of complicated cases. 
- The HCFA generally concurs with our recommendations. It indi-
AGENCY COMMENTS 
cates that effons are also being made to implement and develop uniform definitions of ser
vices. As pan of that effort, it is considering establishment of a uniform reduction in the 
global charge where postoperative services are not performed by the operating surgeon. 
- We are pleased with the HCFA response. We believe the development of
OIG RESPONSE 

national guidelines is the best approach to resolving the inconsistencies in the number of pos
toperative days and the percentage allocation of global fees among Medicare carrers. 
RECOMMENDA TION 
The HCFA should require all carers to instrct both optometrsts and ophthalmologists in the 
use of modifiers when cataract surgery postoperative care is shared with or provided by an op
tometrst. 
- The HCFA concurs and states that a reminder is being made to all
AGENCY COMMENTS 
carrers as pan of the 1989 Common Procedure Code System update. 
-We ar pleased that HCFA concurs and that HCFA is reminding carrers of
OIG RESPONSE 

the use of modifiers. However, we believe HCFA should also ask carers to include a 
reminder on the imponance and use of modifiers in the next newsletter/bulletin issued to the 
physician community. 
RECOMMENDATION 
The HCFA should require all carrers to identify ophthalmologists most likely to permit pos
toperative care by optometrsts. (The inspection found the highest-paid ophthalmologists to 
be most likely to share cataract surgery care with optometrists. 
-The HCFA agrees with thi recommendation. Instrctions were
AGENCY COMMENTS 
physicians with unusually high in
recently issued to carrers requiring detection of those 
creases in payment. These ophthalmologists or ophthalmologists and optometrists wil be sub
jected to an intensified review.  -We are pleased that HCFA has issued instrctions to carrers to identify
OIG RESPONSE 

physicians for review who have had high increases. We believe that HCFA should also issue 
instrctions to carers that require a review of total payments to ophthalmologists in order to 
identify the highest paid ophthalmologists. Our study found that the highest paid ophthal
mologists were those most likely to share cataract surgery follow up care with optometrsts. 
RECOMMENDATION 
The HCFA should require all carers to have the necessar screens in place to detect services 
fee period. 
biled within a global-
- The HCFA concurs with this recommendation, but believes that the
AGENCY COMMENTS 
present claims review requirements provides for such detection. 
- The OIG supports the sections in the Medicare Carers Manual that re-
OIG RESPONSE 

quire carers ' systems to conduct comparsons to ensure proper payment. However , we also 
believe that HCFA should expand the manual so that the comparsons also include a physician-
to-physician review to assess payment when one physician, e.g. an ophthalmologist, bils a 
global fee for cataract surgery and a optometrst bils for a postoperative service during the 
global fee postoperative period. 
RECOMMENDATION 
The HCFA should require all carrers to conduct postpayment reviews of cataract surgery to 
determine: 
if physicians are correctly biling and using modifiers; 
if optometrsts are being paid for services already paid to the ophthalmologist in the 
global fee; and 
the possible existence of arrangements which might violate anti-kickback statutes. 
-The HCFA concurs with this recommendation, and wil enhance
AGENCY COMMENTS 
the present Medicare Carers Manual postpayment review and alert list to address these vul
nerabilities. The HCFA wil consider asking several carers to conduct pilot postpayment 
studies in this area. 
- We suppon HCFA's current efforts to direct and focus postpayment
OIG RESPONSE 

review. However, we believe the areas for postpayment alerts should also be amended to in
clude duplicate payments to physicians when they bil for services that already have been paid 
to another physician as pan of a global fee.  RECOMMENDATION 
The HCFA should require carers to refer any pOtentially abusive arangements between oph
thalmologists and optometrsts, which the carer identifes, to the Office of Inspector General 
for investigations. 
- The HCFA agrees with this recommendation and is emphasizing
AGENCY COMMENTS 
the detection and referral of fraudulent or abusive situations through Manual guidance and 
training, and monitoring of the carers activity and effectiveness. 
RECOMMENDATION 
The HCFA should require mandatory second surgical opinions for elective surgeries paid 
under Medicare. Cataract surgeries, which ar basically elective, would be included for man
datory second opinions by another ophthalmologist.

- The HCFA does not agree with this recommendation. They believe 
AGENCY COMMENTS 
that the present preprocedural review by the PROs wil function as a second opinion and that 
pending regulations wil mandate a PRO second opinion to resolve outstanding uncenainties 
as to the medical necessity of the procedure. 
- In cataract surgery, the accepted indications for surgery are based on the
OIG RESPONSE 

impact of the cataract on the beneficiares ' quality of life as well as on a uniform set of clinical 
measures. Since the preprocedure review progrm concentrates on review of relatively simple 
clinical indications, this program wil not be as effective as the visual 
inspection and consult
ation contemplated in our second opinion reommendation. 
RECOMMENDATION 
The HCFA should require PROs, including local ophthalmologists, to work with their State 
Boards of Optometr to establish review procedures for postoperative cataract surgical care. 
Such review procedures should address the minimum number and frequency of postoperative 
visits, the necessity for 24-hour availability of emergency care, and the presence of written 
agreements between referrng practitioners regarding the division of responsibilities. 
- While HCFA agreed in principle, they indicated that this require-
AGENCY COMMENTS 
ment currently is beyond the scope of the PRO program because PROs do not review care 
provided in practitioners ' offices. 
- We have recommended PRO involvement based upon their role as arbiters
OIG RESPONSE 

of medical practice in their respective States. We feel that the division of responsibility al
lowed by OBRA 86 requires involvement by HCFA and its contractors in ensuring quality of 
care for Medicare patients, who account for the majority of cases in which such divided care 
wil be rendered.
 HEALTH ORGANIZATION COMMENTS 
The OIG issued the draft inspection repon on "Ophthalmology/Optometry Relationships In
volved in Cataract Surgery" for comments to the American Academy of Ophthalmology and 
the American Optometrc Association. Copies of the comments are included in appendix III. 
The following is a summar of the responses received from these organizations. 
The American Academy of Ophthalmology stated that in general they were pleased with the 
findings and recommendations in the repon. However, they urged that we drop the recommen
dation that HCFA develop national guidelines for splitting the global fee and the recommenda
tion that PROs work with the State Boards of Optometr to establish review procedures for 
postoperative cataract surgical care. The Academy commented regarding the rationale for 
refeITs of cataact surgical patients to optometrsts for car. They stated that 
ophthalmologists' services are widely available in urban and rural areas and that the travel dis
tance to an ophthalmologist, for the majority of patients, should never exceed an hour s drve. 
The Academy also recommended a 90-day postoperative period for cataract surgery. 
The American Optometrc Association provided current figures on the number of States that 
permt optometrsts to use diagnostic and therapeutic drgs. They also noted one inconsisten
cy in the repon regarding the services that can be provided by optometrsts following an ex
pansion of coverage. 
- We have reviewed the comments of these organizations but believe that
OIG RESPONSE 

changes to the basic recommendations in the report arenot waranted. We feel that the find
ings establish the requirement for definitive guidelines and the need for a medical review 
presence to ensure the medical necessity and quality of care when services are performed. 
In response to the comment by the American Academy of Ophthalmology regarding the 
geographic dispersion of ophthalmologists, some of the beneficiares whom we contacted in 
our study and who had seen an optometrst for postoperative care stated that there was not 
ophthalmologist that they were aware of in their immediate community. Our report according
ly has included this information as a conclusion of those beneficiares. 
The Academy s recommendation of a 90-day postoperative period coincides exactly with the 
median period used by the Medicare carrers sampled in this review.  APPENDIX I 
OPHTHALMOLOGY/OPTOMETRY SAMPLE 
CARRIER  STATE 
Arkansas Blue Shield, processing claims for  Louisiana 
Blue Shield of California  California (Nonhern) 
Transamerica Occidental of California  California (Southern) 
Blue Shield of Kansas City  Missouri (Western)

Blue Shield of Western New York, Inc.  New York 
(Does not include New York City) 
Prdential of North Carolina
 North Carolina

Aetna of Oregon  Oregon 
Blue Shield of Montana  Montana 
*Two separate samples of 100 each  APPENDIX II 
OPHTHALMOLOGISTS COMPARISON DATA

The inspection found that of the 58 interviewed ophthalmologists who perform cataract 
surgery, 16 (28 percent) said they approved of optometrsts providing their patients with 
catarct surgery postoperative care. The rem  ning 42 (72 percent) felt that optometrsts were 
not qualified to provide postoperative car. The comparson of data between both groups is 
outlined below. The comments address ophthalmologists who allow postoperative care by op
tometrsts. 
Allow  Do Not Allow 
Postop Postop 
Data  Car  Care  Comments 
(16)  (42) 
Average number  A vera  ed fe 
of years in  years In practIce
practice 
Percentage of  79%  59%  Had a higher Medicare
practice with  patient population
Medicare patients 
Percentage of  Performed a higher cataract
surgery performed at:  surgery percentage of their 
surgenes in an ambulatory center
(a) Hospital 26%  71%  (ASC)
surgical 
Outpatient 
(b) ASC 74%  28% 
Percentage of  32%  Received a higher 
cataract surgery  percentage (25% higher)
referrals from  of optometrc referrals 
optometrsts 
Patients always  14 (88%)  41 (98%)
examined by the 
ophthalmologist
prior to the day 
of surgery  Continued 
Allow  Do Not Allow 
Postop  Postop 
Data  Care  Care  Comments 
(16)  (42) 
Patients examned  14 (88%)  41 (98%) 
by the 
ophthalmologists 
the day after 
surgery (24 hr. exam) 
Length of  Follow their 
follow-up by the  patients for a 
ophthalmologists:  shoner time after 
(a) one week or surgery 
less  3 (19%) 
(b) 2-4 weeks  2 (13%) 
(c) 5-7 weeks  2 (13%)  4 (10%) 
(d) 8 weeks 9 (56%)  38(90%) 
Dollars paid  $30,627 042  $39, 155,850  28% of the 
to the sampled 
ophthalmolo  ists  cof liescicteiadn s44% 
during FY 1 87  of the total 
Medicare payments 
for physicIans 
sampled. 
Average payment $ 1 914 190 $ 932 282 
Total: $69,782,892 paid to the 58 sampled physicians  APPENDIX II
 ._-
 -..-... - --..
~~~
"""'''  - - -  ....  ---- 
:::\f 
::TM  Healtt: Care
EALTH iLHV  ERV! 
FinancIng A9mlnlstration

.a.. -.-... .

Memorandum 
0 152 
Date  "L-
William L. Roper,
M. D. 
Administ::ator 
From  LA
OIG Draft Report: 
Ophthalmoloqy/Optometry Relationships in

Subject Cataract Surgery - OAI-07-SS-00460 
The Inspector General

Office of the Secretary

We have reviewed your draft report which addressed the

interrelationship of ophthal 
oloqists and optometrists in

cataract surgeries and the resultant effects on MediQare

reimbursement. 
In the interest of clarity, we are including our response to your

recommendations as an attachment.

Thank you for giving us the opportunity to comment on this dr

report . 
Attachment 
RECEIVED 
JAN 06 19BQ 
OFFICE OFj 
ERA
lMseECIQ.R  are Financin  Administration 
Health 
Comments on OIG Draft ReDort

"ODhtha.lmoloqy IODtometrv Relationsh 
Involved in Cataract Sur erv" 
OAI - 0 7 - 8 a -00460 
Recommendation 1: 
The HCFA should devel-. .national 
quidelines covering the numer
of postoperative days 
petangcleu ded in a global fee for cataract

surgery, and the 
allocation of a global fee to surgery
and postoperative :r:.

HC:'A Cownents: 
We generally agree with the recomendation. 
Our Bureau of 
Quali ty Control has conducted a study of cataract surgery and

associated pre- and postoperative 
services. The study included

all carriers and indicated variances in global fee structures as

well as variances in billing paymt 
practices. We are currently
completing the cataract study and we plan to address the issue of

carrier variances in the structure and paymnt of global
packages. As part 
iJRlcmt 
of our effort to 
and develop unifor:
definitions of services as required by section 4055 (a) (2) of the
Omnibus BUdget Reconciliation Act of 1987
, we are considering

establishing a unifo 
reduction in the global charge where

postcperative services are not performed by the operating

surgeon. 
Recommendation 2: 
The HCFA should require all carriers to instruct optometrists and

ophthalmologists in the use of procedure code modifiers. 
HCFA Comments: 
We are reminding carriers of the 
use of all CPT-4 modifiers as

part of the 1989 HCFA Common Procedure Coding System update.

Recommendation 3: 
The HCFA should require  all carriers to identify ophthalmologists

most likely to permit postoperative care by optometrists.  HCFA Comments: 
We recently issued instructions requiring carriers to calculate

the pe centage of increase in total Medicare payments to

physicians in order to detect those with unusually high

increases. 
Physicians with significant increases 
/ such as the
ophthalmologists operating in tandem with optometrists 
/ will be

detected by this analys s and subj 
ected to more intensified
review. 
Recommendation 4: 
The HCFA should require all carriers to have the necessary

screens in place to detect services billed within a global fee

period. 
HCFA Comments: 
Section 7527 of the Medicare Carriers Manual currently requires

that a procedure-to-
procedure review be done of each claim

submi 
tted for payment to identify  individual procedures which

are normally part of surgical packaallges.
dation 
Recomme 
Th.  HCFA should require  carriers to conduct postp&yat
reviews of cataract surgeall ry to evaluate use of modifiers 

or duplicative payments to optometrists, or the existence/  oefx
cess

kickback 
schemes. 
HC?A Comments: 
The Postpayment Alert List (section 
7514 E of the Medicare

Carriers Manual) lists areas of previously detected p

ogram
vulnerability that carriers should consider when selecting cases

for postpayment review. It currently includes "cataracts 
excessive preoperative visual acuity testing" and "
pre- and post

operative care - not included in global fee 
as applicable,
regardless of the place of service. 
We will add a refe ence
use of the modifiers. The 
existence of kickback schemes would

hopefully be detected as a by-
product of an intensified

postpayment review. In 
addition, we will consider asking several

carriers to do pilot postpayment studies in 
this area.

Recomrenda t ion 

The HCFA should require carriers to refer any potentially abusive

arrangements between ophthalmologists and optometrists 
carrier  / which the
identifies, to the OIG for investigation.  HCFA Comments: 
The Medicare Carriers Manual contains numerous references to the

requirement that all apparent fraud or abuse cases and

uncorrected misbilling cases be referred to 

special ty. We have also instructed the carrOiIeGr,s  rteog apredrlieosdsi coalfl
 y

contact OIG to determine the status of referred 

cases. In
addition, section 11000
, the fraud and abuse chapter undergoing

final changes prior to final Publication, stresses the same

requirements. We 
also devoted much time to this 

recent carrier medical review  subj ect during
the numer of  training. We will be monitoring

FY 89 referrals to dete 
ine whether this new
emphasis has been effective.

Recommendation 7: 
The HCFA should require mandatory second surgical opinions for

elective surgeries paid under Medicare. 
Cataract surgeries,
which are basically 
elective, would be included for mandatory

second opinions by another oph 
almologist 
HCFA Comments: 
We do not believe it is necessary to zandate second opinions for

all cataract surgeries for the followinq 
reasons: 
Under the third Scope of Work, Utilization and Quality

Control Peer Review Organizations 

(PROs) are required to

review 10 procedures on a preadmission/preprocedure basis

and deny payment for any procedure which is not medically

necessary or is proposed to be deli 
v.red in a setting which
is not appropriate. In effec, the PR will 
opinion on the necessity and approriateness orefn tdheer a second
surgery . 
The impending implementation of section 9401 of the

Consolidated 
Omibus 
Budget Reconciliation Act will extend 
preadmission/preprocedure  view to also require the PRO to

mandate a second opinion to resolve outstanding

uncertainties as to the medical necessity of the procedure.

This provision is being implesented through the regulatory

process. 
Recommendation 8: 
The HCFA should require PROs to work with their state Boards of

Optometry to establish review procedures for postopera 
ataract surgical care.  ti ve
Such review procedures should address  the minimum numer 
and frequency of postoperative visits, the
necessity for 24-hour availability of emergency care

presence of written aqreements between referring prac,t iatnido ntehre
s

reqaraing the aivision of responsibilities. 
HCFA Comments: 
Such a requirement currently is 
beyond the scope 0 
porfofqircame sa.s  IPfR Os do not review care  f the PRO
provided in practitioners'

and when PROs beqin reviewinq these services, we
will take this recommendation under 
consideration.  "';;
AI"1ERICAN ACADEI"1Y OF OPHTHALMOLOGY

February 28, 1989

SECRETARIAT FOR 
COVERNMEN  L RELATIONS  Barry Steeley

Mr. 
Office of Analysis and Inspections

Office of Inspector General

Department of Health and Human

Hu..ru R. SIOKts.M.

Secfet  Services 
Post OHice Box F. 
330 Independence Avenue, S.
602 Eut Cheves Street 
Florence. South urolina 29501  Washington, DC, 20201 
Dear Mr. Steeley:

ALL. O. IINUN. M. 
Associoue  Secfe  ry fOf Thank you for the opportunity to review your draft

Federill Economic Policy 
14 West Mount Vernon Place  report entitled, Ophthalmology/Optometry Relationships

Ballimore. Maryland 21201  Involved in Cataract Surgery. The report provides some

MICHAEL A. LEM'- M.  new documentation of the arrangements about which the

Associale SecrelilfY iOf  concern. 
ResearC';I.  Regulatory  "'geneies  Academy has expressed  While its methodology 
and Federal  Systems  and findings appear valid, we would urge you to

Center for Si!hl 
!orgetown Unive"ilY Medical.Center  strengthen some of the recommendations and to attempt

3800 Reservoir Road. S.  to re-verify some of the findings. 
Wilshington. O.c. 2007 
DAvIa W. P.'UE. M. 
"'ssoc/ale SeereliJry ior  Recommendations.  The information you have gathered 
SI.lIe  should permit you to reach the conclusion that

477 Sourh Broad Street 
Merlden. Connecricut 06450  optometrists should NOT be providing post-operative

"'RTHUR M. REv..OLOS. JI.. M.  care following cataract surgery and should NOT be

AsSOCloile  SecrelafY lor  reimbursed for services provided prior to the end of

Federal  Legis/illlon 
1515 Chain Bridge ROild
 the post-operative period. We urge you to delete the

MCLean. Virginlil 22101 
draft recommendation which would require HCFA to

fee. 
develop guidelines for splitting the global  The 
Academy has recommended a 90-day post-operative period

OFFICE OF  for cataract surgery.

COVERNMENTAL RELATIONS 
C." rH... C. ROOf  Qualitv of Care.  The issue of quality is mentioned,

Direclor 
1101 Vermonl Avenue. N.  but not defined or explored. We would refer you to the

Suire 300  October, 1988 report by the Office of Technology

Washinglon . D. C. 20005-3570 
(2021737.6662  Assessment comparing some measures of quality and

training. For example, in your draft, you quote

optometrists as s-aying that they only provide " routine 
follow up care, and would refer any  signif icant"
complications to the operating surgeon. 
The OTA report explains how this situation could lead

to serious complications based on the optometrist not

being qualified to clearly diagnose the significance of

post-operative symp oms, and the crucial delays when

tthhe peatie not isp reeferrread ftroimn thge op tsomeutrirstg bacek
 on. 
This type of situation, as you
are aware, was the subj 
ect last year of a hearing
conducted by the Senate Aging Committee.  (p. 
Further, your draft report does not indicate whether

both the optometrist and the operating surgeon bill

Medicare for i these instances when a patient must be 
referred back to the surgeon, and how much of a

potential additional expense to Medicare this practice

could represent. 
More em hasis on f indinas needed.  We were generally 
pleased with the findings and recommendations made by

the report; however, there are some areas that should

results. 
be strengthened to more accurately portray the 
sumary, " 
In the executive  no direct evidence of poor
quality, 
" is a misleading title, since later in the 
report, there are direct statements that the OIG has

identified: " 
coercion to refer patients and failure to 
adequately provide preoperative and postopertive care.

(p. 4)
Emphasi  in the executive sumary and more attention in 
the body of the report should be given to the findings

not 
o the 
osn usurrgegons ewhro ydo 
  see the patient prior 
(12%, see p. 14) and who do not see the patient 
1ST 
the day after surgery (12%, see p.  The OTA 
report I s 
strongest recommendation regards the necessity 
for a pre-operative examination by the operating

ophthalmologist. 
For example, in North Carolina, where optometrists have

been most successful in expanding their scope of

license through legislative fiat, the Medicare carrier

nonetheless requires that the operating surgeon examine

the patient before cataract surgery, and the day after

surgery. 
Anything less would be a dereliction of
responsibility to the patient I s welfare. 
Another " vulnerability
" which should be included 6in:  the
executive sumary for 
emphasis is cited on page 
60 percent rate of overbilling by optometrists who

submitted claims for services during the global fee

period. 
Also, in your sampling of cases, you uncovered two

contractual arrangements which appear to be highly

questionable, yet these are only noted in passing 

7), and not given any acknowledgement in the executive

sumary. 
care. 
Def ini tion of oDtometric post-o  The draft 
report incorrectly ass  es that state licensure to use

certain drugs also permits optometrists to provide

medical t3re)a.t ment to post-surgical cataract patients

(see p.  There are very important differences 
between the permission to prescribe medications and the

ability to decide on post-operative treatment.  Just because some of the drugs that some optometrists

are permi tted  use happen to include some of the

medications prescribed by ophthalmologis s post

operatively, does not grant ability to make a medical

determination regarding the appropriate use of the

drugs during surgically-related treatment. 
Even if you should conclude, contrary to our view
, that

optometrists. may be qualified to perform some post

operative care in states where they are permitted to

use and prescribe certain therapeutic drugs, such a

conclusion clearly does not support the notion that

optometrists are qualified to provide post-operative

care in states where they are not authorized to

prescribe therapeutic drugs.

These are key points, and must be corrected in the

report. 
Of the eight states studied, only three permit 
optometrists to prescribe a short list of "therapeutic
drugs. All 
exclude surgery from the optometrist I
scope of practice. Only Colorado addresses the

question of post-operative care. The state

legislatures passed these laws generally to allow

optometris 
s to care for minor eye irritations, such as 
red eye, not for the treat ent of post-surgical

patients. 
Compr1  es in post-operative eye care may have been 
encouraged by the Medicare payment policy begun in 1986 
of permitting operating surgeons and referring

optometrists to split the global surgical fee simply by

using designated modifiers on Medicare claims forms. 
As a result, the Medicare program in essence, has

singled out eye care patients for inadequate post

operative care in the hands of persons other than

medical doctors. 
Licensina Boards.  It is our general understanding that

the Boards of Medical Examiners in all the states

consider surgical care, including post-operative care,
to be part of the care and tre tment for which they

license medical doctors. Optometrists are licensed

under an independent. Board of 
Optometry't not subj ect to 
the same licensing requirements as ophthalmologists or

other medical doctors. This raises two points which

must be addressed in the report: 
( 1) 
That any statewide decision on the practice of 
medicine must include the Board. of Medical Examiners.

The recommendation for the Board of Optometry to decide

on the division of post-op care (see p. 12) is probably

not lawful, and certainly insufficient, undesirable,

This recommendation should be deleted

afnrd ounnmecess artyh. e report.  ( 2) 
not
The ability to prescribe certain drugs 
synonymous with the ability to treat a post-ois perative

patient. 
The surg.eon must choose from 
a wide array of
medications and other interventions, as well as

deciding when not to add or change medications. 
optometrist I s  The 
strictly limited
in every state,pre scwribhinig acuthhor itpy
 revents the wisi de. choice 
treatments necessary to ensure appropriate care of the

patient. 
Reason for Referral.  The draft report states that:
the major reason patients returned to an optometrist

for postoperative care was the distance involved in

traveling back to the operating surgeon.

This has

always been an unsupported assertion which must be

documented. 
We won er whether the OIG field researchers checked on

the location of the patient' 
s home, the distance

traveled to the optometrist, the distance traveled to

the operating ophthalmologist. 
We wonder whether the 
field researchers documented that there were no closer

ophthalmologists from whom the patient could receive

both surgical and POst-operative cataract 
care. We

wonder whether the researchers compared the travel

distances for patients of those ophthalmologists who

had a high volume of cataract referrals from

optometrists with travel distances for patients of

ophthalmologists who had only a small numer of
optometric referrals.

Based on zip code studies of ophthalmologists, the
Academy has concluded that ophthalmologists are widely

distributed among urban and rural 
areas, and that only

a tiny fraction of the population 
 more than an

hour' s drive from an ophthalmologis  ist. 
We strongly 
suggest that before this report 
 finalized, your

field researchers go back and veris ify the assertion that

referrals are " 
necessary
" because of the unavailability
of ophthalmologists.

If other local ophthalmologists are 
available, then it

clear that referral patterns which result in

is 
optometrists sending patients to surgeons who are too

far away to provide postoperative care are patterns

which should be investigated for Medicare anti-kickback

violations.  Thank you for the opportunity to comment on this draft

report. 
Sincerely, 
/L 
Hunter Stokes, MD

Secretary  :-. 
--- -  --  , - 
. 1 If .. 
I H 

American Optometric Association 
. 1989 
I L:.  1505 Prince Street. Alexandria. VA 22314. (703) 739-9200 
FAX: (703) 739-9497 
a ; 
 uary 31 
Mr. Mi ke Mangano

Assi stant Inspector General

for AnalYSis and Inspection

Department of Heal th and Human  Servi ces 
330 Independence Avenue. S.
Room 5660 
, D. C. 
Washington  20201 
Dear Mr. Mangano:

The American Optometric Association appreciates the opportunity to review the

draft document 
 Oohthalmoloov/Ootometrv R Litionshios Involved in Cataract

and would like to offer the following comments for consideration.

Executi ve Summary 
age i  The correct number of states permi tti ng optometri sts to use 
diagnostic and therapeutic drugs is SO and 23. respectively (see

attached). It is important to note that post-operative care coordinated

between optometri sts and ophtha 1 mi c surgeons is not dependent on the use 
of therapeuti c drugs.

age i i i  We are unc1 ear how the two comments under the headi ng of 
vulnerabilities 
quality of care relate to " . and we believe. based on

the study fi ndi ngs. that vu  nerab i  es is not the proper word for th
1 i ti 
heading. 
It is not surprising that ophthalmologists who comanage patients with

optometrists generally follow their patients for a shorter period, since

two providers are involved in the post-operative episode. The number of 
visits in this case will be consistent with other models of care. and as

the draft poi nts out. optometri sts conti nue to communi cate and consul 
with the ophthalmic surgeon on possible complications. 
This passage
woul d appear to poi nt out a strength inherent 1 n comanagement. not a
vulnerability. 
place. 
The reference to second opinions appears out of 
Whi le the 
possible use of second opinions may address questions of volume and

overutilization 
. it does not represent a potential vulnerability to the 
rendering of quality post-operative care. 
We be  the reference to mi n i mum number and frequency of
1 i eve 
visits should relate to uncomplicated cases. 
Headquarters: 243 N. Lindbergh Blvd. . St Louis. MO 63141 . (314) 991-4100. FAX: (314) 991-4100  ...
,,

Introduction 
fg..U --
The reference it.o the Ameri can Academy of Ophtha 1 mo logy ' 
correct. 
e th i ca 1 standards regarding post-operati ve care is not  The 
post-operative 
section of th  AAO Code of Ethics, conditionally approved 
by the Federal Trade Coni:ss1on, states that the ophthalmologist should

provide " those aspects ,of eye care within the unique competence of the
ophthalmologist (which 00 mtt  include those permitted by law to be 
performed by auxiliaries.  The FTC opinion conditionally approving

the AAO Code states speclfiiocal1y that li the rul e wou1 d not prevent
ophthalmologists from arr 
glng for optometrists to provide 
post-operative eye care $iE!r!fj'ces  consistent with state law" (opinion 
enc 1 osed) . 
Page 3 -- The last sente1i(ce of the first paragraph implies that the 1980

Omni bus Reconci  iation A'ct ame'ndment  a11owed optometri sts to bi 
Medicare only for detenn'1:ni:rng visua1 acuity, prescribing glasses, and 
dispensing optical devh:::es.. This is not correct. The law provided for 
payment for all examinat10n services related to aphakia consistent with

state 
period1 a.w  , whi ch 1 ncl ude cff' h::e EJc,am1nations duri ng the post-operat1 ve
The HCFA regulati.oms lmpleimenting this change confirmed this 
of 
intent and provfded example:s  s:uch servi ces. Again , the correct
reference to di 
md tnera eutic states is 50 and 23. 
agnosti c 
The description of the e;Jrpa;rlaed coverage of optometrists ' services 
provided under the Omnibils Bwd' get Reconciliation Act of 1986 (OBRA 1986)
is not enti 
rely accurate. It suggests that the expansion is narrowly 
eratlv 
applicable to the post-o  period in a cataract patient. Page i 
of the draft report more accurately notes that OBRA 1986 authorized

Medi care coverage for vi silon (,are servi ces furn ished by an optometri st, 
to all Medicare eligible patients. if the services are among those

covered under Medicare and if the optometrist is legally authorized

under state scope of practice law to perform the service. 
Fi ndi ngs 
Pace 6 -- The first paragraph describes an overpayment si tuation and 
implies that it was the optometrist who billed and was paid

inappropriately. 
Similarly. on page ii of the summary it is stated that 
optometrists also billed Medicare inappropriately for services

duri ng the period  II In fact, it 
encompassed by the global fee.  is the 
ophthalmologist who billed inappropriately for services he or she did

not provide , and, in such cases. it is the ophthalmologist who

overpaid, not the 
optometrist. We believe the report should state
clearly that a physician biiiilly 
a gluuaJ fee should provide all the 
services covered under the global fee or use a'modifier to note that

some of the package of services will be provided by another practitioner.

Page 9 -- The report notes that the ophthalmologists interviewed were

significantly divided on the issue of optometrists providing

post-operative care. however only the majority opinion is stated. 
as sume that the 28 percent who comanage wi th optometri sts di d not agree 
with their  f optometric post-operative care 
colleagues on the quality 
and believe this should be highlighted.

Again , we question the appropriateness of the word Ivulnerabi1ities " and 
section. 
the relevance of the second opinion discussion to this  See 
comment on execut1 ve summary page i1 i .  -- 
y, .

Paae 10 -- We would suggest t.hat the heading for lOb be changed to 
Quality Considerations  , sioca the report has stated there is no direct

evidence of poor quality care. We again question the comment on

ophthalmologists who refer to optometrists following their patients for

i i i. 
a shorter period of time as in executive summary page 
Recommenda ti ons 
Paae  identify
We bel ieve the third recommendation should read " 
other
ophthalmologists most likely to permit post-operative care by 

oroviders 
" so as to include referrals to other ophthalmologists for 
post-operative care. We are also concerned that the reference in this

recommendation to "highest paid" could be interpreted to mean that these

ophthalmologists charge more per procedure, which does not seem to be

the case. They recei ve more payments because they provi de a greater 
volume of service. 
we-1 --
The reference to second opinions should state "by another 
ophthalmologist or optometr'st"  Optometrists are clearly qualified to

render an op in i on on the necess 1 ty of cataract surgery and as the report 
notes earl ier ' 
bn page 10, are asked to do so on occasion. 
As s ta ted before in executi ve summary page iv , we be 1 i eve the reference 
to minimum number and frequency of visits should relate to uncomplicated

cases. 
draft. 
Thank you for the opportunity to review and comment on this  We wou1 d 
be happy to meet wi th you to di scuss our comments and the report. 
Sincere 
Jeffrey G. Mays

Washington Office Director

Attachment 
JGM/N. Goff

0191F