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Cataract Surgery Anesthesia Models

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dantt

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We are considering an anesthesia group who's model is out-of-network for all insurances for an eye surgery center. I guess there are a few insurance companies that pay beaucoup bucks for out of network charges. I personally find this a little distasteful and am worried patients will be hit with a surprise charge and this will blow back on us. That being said, I've been told by some of our anesthetists they've been proposed medicaid rates by some insurance carriers and that's not right either.

How common is this model? How much does medicare pay for cataract surgery anesthesia? What is the range insurance companies pay and what is the cash pay market like? I hear on this forum and many others don't erode the profession by choosing CRNAs over MDs but are many MDs willing to work for what medicare/insurance pays? Margins are tight and subsidies by the ASC to the anesthesiologist would be totally out of the question.
 

IMGASMD

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We are considering an anesthesia group who's model is out-of-network for all insurances for an eye surgery center. I guess there are a few insurance companies that pay beaucoup bucks for out of network charges. I personally find this a little distasteful and am worried patients will be hit with a surprise charge and this will blow back on us. That being said, I've been told by some of our anesthetists they've been proposed medicaid rates by some insurance carriers and that's not right either.

How common is this model? How much does medicare pay for cataract surgery anesthesia? What is the range insurance companies pay and what is the cash pay market like? I hear on this forum and many others don't erode the profession by choosing CRNAs over MDs but are many MDs willing to work for what medicare/insurance pays? Margins are tight and subsidies by the ASC to the anesthesiologist would be totally out of the question.

I will share with you, if you share with me….
How much do you typically get reimbursed for a cataract?

I will go first.
I looked up, because I don’t do billing either. Apparently it’s worth 4 base units and probably 2 time units. So probably a ~ 6 unit procedure.

At medi-whatever rate @ 6 = what we generate.
 

dantt

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I will share with you, if you share with me….
How much do you typically get reimbursed for a cataract?

I will go first.
I looked up, because I don’t do billing either. Apparently it’s worth 4 base units and probably 2 time units. So probably a ~ 6 unit procedure.

At medi-whatever rate @ 6 = what we generate.
Sure. National payment amount for 66984 is $544. Some things to keep in mind. This includes 90 days of postop care and there's more overhead associated with that than what happens in the operating room (techs, rent, etc).

Unfortunately all us non anesthesia providers don't understand what units are, base units or time units. What is the average medi-whatever rate?
 

Hoya11

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Sure. National payment amount for 66984 is $544. Some things to keep in mind. This includes 90 days of postop care and there's more overhead associated with that than what happens in the operating room (techs, rent, etc).

Unfortunately all us non anesthesia providers don't understand what units are, base units or time units. What is the average medi-whatever rate?
i think my group has great rates and per cataract our take home is significantly lower than that, maybe slightly more than half of that figure. and thats when its all said and done across all payers with a decent mix.

ill tell you the honest truth. the reimbursement for cataracts is horrible. if you dont have a huge volume operation AND a group that has great rates its not worth it. Currently even with our great rates and doing 30 a day its barely worth it for us due to a minimal margin.

We have walked away from centers where the volume did not generate a margin. Lots of groups have. Big potential to be a money loser and small potential to be a small money gainer. Never will it be a huge bread winning center.

The group you are talking to must have not great rates or you are demanding staff coverage that is too much. I would believe them that the only way to make money is to be out of network. It takes a big group (hospital size) to have the rates you need to get this done without subsidizing the group. Would you rather you subsidize or the patients?
 
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IMGASMD

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Thank you.

An anestheia unit rate for medi-care is $21.50
So $130….. with the same concerns as you. Post op complications/complaints, overhead. Don’t have to follow them through 90 days, thank God.

Private insurance unit rate is whatever the group can negotiate up to…..
 

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Medicare rates are around 21 and medicaid I lost like 13.

So if you can manage 3 procedures per hr..then you are looking at around 15-16 units per hr ($315). Only 2 procedures and you are looking at 12 units ($250 per hr) at medicare rates.

Cash rates for plastics can hover around $300-350 per hr..so it's much easier to to one plastics case than 3 eye cases.
 

dantt

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I suspected it would not be worth it for an anesthesiologist. Would it be worth it for a CRNA? Again slightly pushing back on the no CRNAs mentality on this and many other forums. I think we have demanded too much coverage from anesthesia in the past and market realities are coming sooner rather than later due to COVID.
 

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We are considering an anesthesia group who's model is out-of-network for all insurances for an eye surgery center. I guess there are a few insurance companies that pay beaucoup bucks for out of network charges. I personally find this a little distasteful and am worried patients will be hit with a surprise charge and this will blow back on us. That being said, I've been told by some of our anesthetists they've been proposed medicaid rates by some insurance carriers and that's not right either.

How common is this model? How much does medicare pay for cataract surgery anesthesia? What is the range insurance companies pay and what is the cash pay market like? I hear on this forum and many others don't erode the profession by choosing CRNAs over MDs but are many MDs willing to work for what medicare/insurance pays? Margins are tight and subsidies by the ASC to the anesthesiologist would be totally out of the question.

I don’t think it’ll work too complicated and Hugh change of running into regulatory problems. Maybe if done upfront could work.
 

IMGASMD

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I suspected it would not be worth it for an anesthesiologist. Would it be worth it for a CRNA? Again slightly pushing back on the no CRNAs mentality on this and many other forums. I think we have demanded too much coverage from anesthesia in the past and market realities are coming sooner rather than later due to COVID.
It just depends on how risk adverse you are, right? If you are welling to undertake some of the anesthesia risks from CRNAs, then you’re okay. It includes some of the pre-op risks. Someone will need to decide how suitable the patient is for procedure and what kind of the work up is needed…..

Or as my above colleagues pointed out, subsidize anesthesiologists to a reasonable rate and/or be more efficient.
 

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I suspected it would not be worth it for an anesthesiologist. Would it be worth it for a CRNA? Again slightly pushing back on the no CRNAs mentality on this and many other forums. I think we have demanded too much coverage from anesthesia in the past and market realities are coming sooner rather than later due to COVID.

Probably. Wasn't there a news story about a CRNA who offed someone during an eyeball surgery recently because they hadn't intubated in 5 years. I know at my shop with the ACT model I have been told we lose money on every cataract.
 
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RadsWFA1900

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Are there actually any eye surgery centers that subsidizes the anesthesiologists?

You should check out the optho forum

Already trying to do it without any anesthesia crna or otherwise
 

ValentineD

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You should check out the optho forum

Already trying to do it without any anesthesia crna or otherwise

We have one surgeon who does his cataracts with just topical AND anesthesia present. I've often wondered why.
 
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dantt

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You should check out the optho forum

Already trying to do it without any anesthesia crna or otherwise
I've seen that thread and cross-posted a similar issue. To be clear none of us want to do surgery without anesthesia present and have pushed back hard against the insurance companies that would have us do it (Anthem tried a few years ago). I hope anesthesiologists also pushed back against it but I never heard where you all did. It sounds like that OP temporarily lost anesthesia coverage at their ASC.

@ValentineD we do our surgeries with topical anesthesia...problem is if the patient is uncomfortable, can't hold still, etc. There's a limit to verbal anesthesia.
 
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Southpaw

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We are considering an anesthesia group who's model is out-of-network for all insurances for an eye surgery center. I guess there are a few insurance companies that pay beaucoup bucks for out of network charges. I personally find this a little distasteful and am worried patients will be hit with a surprise charge and this will blow back on us. That being said, I've been told by some of our anesthetists they've been proposed medicaid rates by some insurance carriers and that's not right either.

How common is this model? How much does medicare pay for cataract surgery anesthesia? What is the range insurance companies pay and what is the cash pay market like? I hear on this forum and many others don't erode the profession by choosing CRNAs over MDs but are many MDs willing to work for what medicare/insurance pays? Margins are tight and subsidies by the ASC to the anesthesiologist would be totally out of the question.

All Medicare right? I understand why an anesthesia group would push the envelope with out of network when 100% of their patients are medicare/Medicaid, but I don’t agree with that model. It’s unethical and unfair to the patient.

That said, an anesthesiologist working for a center for Medicare rates, doing 2 cataracts an hour (includes turnover and random delays) could probably make $200-250 an hour (12 units at about $23 per unit).

You may be able to find a group who would stay in network and do the work for you. There are benefits, mostly ASC hours with no nights/weekends/holidays.

On hiring a CRNA group as an alternative, I don’t know what to tell you. My hope is you could find a decent group of anesthesiologists to provide coverage for you.
 

dantt

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All Medicare right? I understand why an anesthesia group would push the envelope with out of network when 100% of their patients are medicare/Medicaid, but I don’t agree with that model. It’s unethical and unfair to the patient.

That said, an anesthesiologist working for a center for Medicare rates, doing 2 cataracts an hour (includes turnover and random delays) could probably make $200-250 an hour (12 units at about $23 per unit).

You may be able to find a group who would stay in network and do the work for you. There are benefits, mostly ASC hours with no nights/weekends/holidays.

On hiring a CRNA group as an alternative, I don’t know what to tell you. My hope is you could find a decent group of anesthesiologists to provide coverage for you.
Almost all Medicare. Truth is that's who needs cataract surgery. That being said, the insurance market is not that much better. We don't have any commercial payors paying less than Medicare but they exist. Right now we push high risk patients to the hospital when we have time or refer them out to practices with large hospital presences.
 
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nimbus

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I’ve never heard of any large anesthesia group that opts out of Medicare. You either participate in Medicare and accept assignment for all Medicare patients or you don’t. If you don’t, you lose a lot of business. Maybe a small group or individual that does primarily cash pay office work can opt out. It would be impossible for any group that works in a hospital.
 
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Hoya11

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Are there actually any eye surgery centers that subsidizes the anesthesiologists?
one model is to hire the crnas and docs yourself - so in essence that is subsidizing them because thats the model you take when your not going to make any money on the anesthesia services and you cant find anyone to do it. you just employ it yourselves and break even or take a small loss (but overall gain for the facility fees)

the other model is to do this at a center with huge volume where it makes sense and you can do 30+ a day ( or be part of 30+ a day).

hiring CRNAs to do it alone is fine but the liability is on you. and there are issues that come up that will be handled poorly for the center.. that CRNA going to treat new AF? deal with an emergency? probably nto well
 
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In general, the only model that financially works for a free standing cataract center without a subsidy is CRNA only. Might work financially for a doc supervising CRNAs if it is a high volume turn and burn 3+ rooms every day you have anesthesia personnel. Might also work for a doc if you don't mind a problem CV or a past.

From a patient safety standpoint, could work as CRNA only If your center is no General Anesthetics, (100% MAC). You have a hospital where you can take your sick/demented/can't lay flat/horribly anxious patients, your optho docs are all pretty slick technically and with patient selection and communication during surgery. You also need to cherry pick from the right side of the experienced CRNA skill and judgement curve.
 
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dantt

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In general, the only model that financially works for a free standing cataract center without a subsidy is CRNA only. Might work financially for a doc supervising CRNAs if it is a high volume turn and burn 3+ rooms every day you have anesthesia personnel. Might also work for a doc if you don't mind a problem CV or a past.

From a patient safety standpoint, could work as CRNA only If your center is no General Anesthetics, (100% MAC). You have a hospital where you can take your sick/demented/can't lay flat/horribly anxious patients, your optho docs are all pretty slick technically and with patient selection and communication during surgery. You also need to cherry pick from the right side of the experienced CRNA skill and judgement curve.
Thanks for the post. I thought as much and we have almost always been pretty happy with CRNA only. Unfortunately COVID related changes have soured the relationship and were now looking at options. There has been lots of posts here and other places lamenting practices that choose CRNA over MD but there seems to be no great solution for that here. We're not even trying to make money off anesthesia. It is just out of the question to subsidize MDs to the compensation level expected. (or apparently any other free standing cataract place. The out of network group would also be sending CRNAs).
 
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Howard888

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Unless you have a commercial mix of cataracts higher than the average ophthalmologist, a day of cataracts does not cover the cost of an MD or a CRNA with the salaries they are getting now. Maybe if you did 30 a day like one poster said, but even then it’s not worth the hassle.

The only reason we do cataracts is because you typically have to in order to get other business: if it’s a mixed specialty center to get the ortho or ent or if it’s an all eye center it’s usually because the eye center is owned by the hospital who you cover their other services. If it’s an all eye center has a heavy retina service line that can float the cataracts too that may be worthwhile.

But the reason Anesthesia didn’t push back on Anthem was because we don’t make any money on cataracts and they definitely don’t provide enjoyment for us to do. If the commercial mix was closer to 50% that would be a different story.

I know of many centers where cataracts are done with oral sedation without anesthesia and non cataract cases of other specialties are done with anesthesia.

This is the future model. Either learn to do it or get ready to pay a stipend if you only plan on doing cataracts
 
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I think there are plenty of CRNAs who’d do cataracts at an ASC. The ophtho group would pay a 1099 flat rate and deal with collections. I bet they’d break even.

Again, 2-3 cataracts an hour (12 units for 2, 18 for 3) at medicare rates would cover the cost of a CRNA. I imagine some MD only anesthesia groups out west would do this work, as part of larger coverage, for the sake of being good community/corporate citizens.
 
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Mman

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I believe most cataracts at this point are done without any sort of anesthesia involvement, at least that is my perception at hospitals and outpatient centers I am aware of. Surgeon orders a dose of oral or IV benzo and topicalizes from there.
 

IMGASMD

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We still do them at the asc. There are a few who would routinely line 12 patients before 12. And they’re the fast ones. They also have partners who would do retinas, so I suppose that’s why we tolerate them.

You maybe be able to find someone for 200/hr * 6 hrs = ~1200. You can advertise it as such in the community, that you provide anesthesia services to drum up more business.

To those who actually know, is there a way to balance bill the patients if you’re in-network or Medicare patients?
 

nimbus

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I imagine some MD only anesthesia groups out west would do this work, as part of larger coverage, for the sake of being good community/corporate citizens.


We do. And because we spread the pain by pooling our units, it turns out to be a good day for any individual doc who does the lineup even though it hurts us as a group.
 
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Mman

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To those who actually know, is there a way to balance bill the patients if you’re in-network or Medicare patients?

off the top of my head always illegal to balance bill Medicare and laws vary by state for insured patients, but not able to in most states
 
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nimbus

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We still do them at the asc. There are a few who would routinely line 12 patients before 12. And they’re the fast ones. They also have partners who would do retinas, so I suppose that’s why we tolerate them.

You maybe be able to find someone for 200/hr * 6 hrs = ~1200. You can advertise it as such in the community, that you provide anesthesia services to drum up more business.

To those who actually know, is there a way to balance bill the patients if you’re in-network or Medicare patients?


The ability to balance bill medicare patients went away in the early 1990s. That caused a great deal of upheaval at some hospitals in retirement/resort communities. Some patients would show up to the hospital in Bentleys, but all of a sudden you couldn’t balance bill them.
 
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Howard888

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You all are just stating the obvious..best cases scenario is a room full of cataracts might pay for a crnas salary because of the high govt mix

We only tolerate/do cataracts if they come with other specialties/procedures. Now that it has been clearly proven you don’t need an anesthesia provider (Crna or MD) to do cataracts successfully we have the thread above.

The govt should stop paying for cataracts just as they are stopping for epidural steroid injections. We all know that anesthesia is not needed for either and if you had to pick one of the to it would not be cataracts
 
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nimbus

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You all are just stating the obvious..best cases scenario is a room full of cataracts might pay for a crnas salary because of the high govt mix

We only tolerate/do cataracts if they come with other specialties/procedures. Now that it has been clearly proven you don’t need an anesthesia provider (Crna or MD) to do cataracts successfully we have the thread above.

The govt should stop paying for cataracts just as they are stopping for epidural steroid injections. We all know that anesthesia is not needed for either and if you had to pick one of the to it would not be cataracts

It depends a lot on the surgeon. If they can routinely complete a procedure in 5-10min, they don’t need anesthesia because most patients can lie still for 10-15min. Otoh, some docs take 30-45 min and their patients require some carefully titrated sedation to lie still the whole time.
 

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You all are just stating the obvious..best cases scenario is a room full of cataracts might pay for a crnas salary because of the high govt mix

We only tolerate/do cataracts if they come with other specialties/procedures. Now that it has been clearly proven you don’t need an anesthesia provider (Crna or MD) to do cataracts successfully we have the thread above.

The govt should stop paying for cataracts just as they are stopping for epidural steroid injections. We all know that anesthesia is not needed for either and if you had to pick one of the to it would not be cataracts
Say it with your chest!
 

dantt

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We still do them at the asc. There are a few who would routinely line 12 patients before 12. And they’re the fast ones. They also have partners who would do retinas, so I suppose that’s why we tolerate them.

You maybe be able to find someone for 200/hr * 6 hrs = ~1200. You can advertise it as such in the community, that you provide anesthesia services to drum up more business.

To those who actually know, is there a way to balance bill the patients if you’re in-network or Medicare patients?
All of our docs can do 12 before 12. Can we do 15 before 12 (15 x 2 = 30)? Sometimes. I heard from the anesthetists though that it's the cataracts that are subsidizing retina, cornea, plastics, and other cases though, not the other way around. Is that not true?
 
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All of our docs can do 12 before 12. Can we do 15 before 12 (15 x 2 = 30)? Sometimes. I heard from the anesthetists though that it's the cataracts that are subsidizing retina, cornea, plastics, and other cases though, not the other way around. Is that not true?

More cases means more startup units. It depends on how long it takes. But more importantly payor mix and cataracts are mostly medicare. I wouldn't listen to nurses, they rarely have a clue.
 
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jwk

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I believe most cataracts at this point are done without any sort of anesthesia involvement, at least that is my perception at hospitals and outpatient centers I am aware of. Surgeon orders a dose of oral or IV benzo and topicalizes from there.
We're involved with cataracts because our ophthalmologists want us there and at the volume we do, it still makes financial sense. Most are done with topical, and some IV midaz and occasional fentanyl.

We still have a small group of eye docs that insist on doing PB or RB blocks for every cataract case, even though the majority of cataract cases have been done with topical only for more than two decades.. For those, we give a little propofol, which adds cost to the patient in both anesthesia time and hospital costs.
 

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All of our docs can do 12 before 12. Can we do 15 before 12 (15 x 2 = 30)? Sometimes. I heard from the anesthetists though that it's the cataracts that are subsidizing retina, cornea, plastics, and other cases though, not the other way around. Is that not true?
Not possible...they likely have no idea how billing actually works
 
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Southpaw

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Not possible...they likely have no idea how billing actually works

It is possible, depending on volume.

12 cataracts by noon is 48 base units + 24 time, most likely. That’s 72 total units. At Medicare rates ($23/unit) that’s $1656 by noon, for one room.

A retina (1 more base unit) or a plastics (1 less base unit, I think) room doesn’t typically have the volume and therefore the startup units to keep up with the cataract room.


I don’t understand why some of you are saying that won’t work for MD only, even at Medicare rates. If said again, prove it with math. This is at an ASC, so ASC hours. What’s the typical rate for 7-3 for a MD at an ASC? $1200-1500? The Medicare only cataract room beats that by noon with an efficient surgeon.

Also, to be clear, if a CRNA only group gets this contract and they do their own billing they’ll bill at the exact same rates and units as a MD, and therefore make MD money. Want to make sure @dantt understands that, though it doesn’t appear they have a lot of options which is the case for most areas of the country.
 
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IMGASMD

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It is possible, depending on volume.

12 cataracts by noon is 48 base units + 24 time, most likely. That’s 72 total units. At Medicare rates ($23/unit) that’s $1656 by noon, for one room.

A retina (1 more base unit) or a plastics (1 less base unit, I think) room doesn’t typically have the volume and therefore the startup units to keep up with the cataract room.


I don’t understand why some of you are saying that won’t work for MD only, even at Medicare rates. If said again, prove it with math. This is at an ASC, so ASC hours. What’s the typical rate for 7-3 for a MD at an ASC? $1200-1500? The Medicare only cataract room beats that by noon with an efficient surgeon.

Also, to be clear, if a CRNA only group gets this contract and they do their own billing they’ll bill at the exact same rates and units as a MD, and therefore make MD money. Want to make sure @dantt understands that, though it doesn’t appear they have a lot of options which is the case for most areas of the country.

He needs the volume and consistency to have someone who will be welling to stick to it.

That’s why I don’t think it’s unreasonable if the group just hire someone who’s welling to do it and “subsidize” at times.

Anesthesia may smooth out your process. Rather than 2 per hour, you maybe get 2.3/hr so book even more cases!
 

Southpaw

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He needs the volume and consistency to have someone who will be welling to stick to it.

That’s why I don’t think it’s unreasonable if the group just hire someone who’s welling to do it and “subsidize” at times.

Anesthesia may smooth out your process. Rather than 2 per hour, you maybe get 2.3/hr so book even more cases!

No one will be willing to subsidize an ASC eye center. They shouldn’t IMO. It is what is is. There’s no unpaid service, no call, no trauma, no medicaid OB, etc.
 

kidthor

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He needs the volume and consistency to have someone who will be welling to stick to it.

That’s why I don’t think it’s unreasonable if the group just hire someone who’s welling to do it and “subsidize” at times.

Anesthesia may smooth out your process. Rather than 2 per hour, you maybe get 2.3/hr so book even more cases!
Really the ASC/institution/optho-dept needs to subsidize cataract anesthesia if they truly want it. They're making crazy facility fees and surgeon professional fees and if they "need" anesthesia they'll have to pay for it if it's a money loser for us. Why are we acting like the supermarket loss-leader for the others to make a profit? Plus let's be real - nobody actually needs anesthesia for a cataract.
 
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kidthor

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This thread is evidence why private equity is able to exploit us.
It's crazy that we're providing so many services at a loss with an endgame of providing them for an even bigger loss. Totally unclear how this will get any better unless there are big subsidies provided, which puts us in a precarious begging position. The real solution is to improve CMS rates but that'll be a tough row to hoe.

Other endgames are single payor and Kaiser. I don't see devolving FFS rates (especially with CMS payors) as sustainable in any way.
 

IMGASMD

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“Subsidize” in the sense that the eye center should just employee whoever wants to do these kind of cases. but point well taken, why amc/pe will gobble up some practices and make everyone employees and exploit our “time” by jamming more cases into the schedule.

@kidthor. I asked their rate trying to figure out what their margin is. Not spectacular, but for 20 min procedure, ain’t bad. With facility fees, and anesthesia fee. With the little efficiency they can squeeze out with anesthesia and turn over. Probably still be ahead.

Going back to OP, how would it work if all the cases are billed as “out of network”? Or you mean the group will take Medicaid rates, but for all private patients they will book OON?
 
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DesiredMemberName?

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It is possible, depending on volume.

12 cataracts by noon is 48 base units + 24 time, most likely. That’s 72 total units. At Medicare rates ($23/unit) that’s $1656 by noon, for one room.

A retina (1 more base unit) or a plastics (1 less base unit, I think) room doesn’t typically have the volume and therefore the startup units to keep up with the cataract room.


I don’t understand why some of you are saying that won’t work for MD only, even at Medicare rates. If said again, prove it with math. This is at an ASC, so ASC hours. What’s the typical rate for 7-3 for a MD at an ASC? $1200-1500? The Medicare only cataract room beats that by noon with an efficient surgeon.

Also, to be clear, if a CRNA only group gets this contract and they do their own billing they’ll bill at the exact same rates and units as a MD, and therefore make MD money. Want to make sure @dantt understands that, though it doesn’t appear they have a lot of options which is the case for most areas of the country.
24 time units before noon? I guess if you start at 6am and have 0min turnovers.
 
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dA pilot

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24 time units before noon? I guess if you start at 6am and have 0min turnovers.
You can have 0 minute turnovers if surgeon has 2 rooms. Circulating nurse takes patient out while you walk into next room.

My group covers a busy eye center. Md only. Surgeon has 2 rooms. Zero minute turnovers. 20-35 cases a day. You will make money. You do not need to bill out if network. You just have to decide is it worth it.
 

DesiredMemberName?

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You can have 0 minute turnovers if surgeon has 2 rooms. Circulating nurse takes patient out while you walk into next room.

My group covers a busy eye center. Md only. Surgeon has 2 rooms. Zero minute turnovers. 20-35 cases a day. You will make money. You do not need to bill out if network. You just have to decide is it worth it.
If the surgeon/center want to invest in that arrangement, that would certainly optimize the efficiency from our perspective and could make it worthwhile.
 

dipriMAN

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You can have 0 minute turnovers if surgeon has 2 rooms. Circulating nurse takes patient out while you walk into next room.

My group covers a busy eye center. Md only. Surgeon has 2 rooms. Zero minute turnovers. 20-35 cases a day. You will make money. You do not need to bill out if network. You just have to decide is it worth it.
So how does this work, you don’t see the patient preop and review their chart and sign consult with them in the operating room when you walk next door?
 
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