In a question and answer session, four leading ophthalmologists share their experiences with crosslinking, offering pearls that can help peers incorporate the procedure into their practice.
For a quartet of leading ophthalmologists, crosslinking isn’t a business proposition—it’s a mission. But starting from that foundation, they have also found ways to integrate cross-linking into their practices in a way that has helped to build and sustain strong practices.
The four surgeons discussed their experiences in a Q&A session. The participants include:
Q: Why did you get involved with corneal cross-linking and what has it meant for your practice?
John Berdahl, MD: Cross-linking is no longer a new way to treat patients with keratoconus. It is the established standard of care. But I think we shouldn’t lose sight of how valuable it is to have a one-time, FDA-approved treatment to slow or halt progressive keratoconus. The ability to take an irregular cornea, stabilize it, prevent a corneal transplant, and maybe even do a refractive procedure to normalize the shape of the cornea down the road is nothing short of life-changing for our patients.
Brandon Baartman, MD: Nobody is born with corneas shaped like cones. So, when we see progression from keratoconus—particularly in young people—we have a responsibility to address it. I consider it a privilege to be able to offer my patients cross-linking; it is one of the most meaningful things I do.
Jack Parker, MD, PhD: In our cornea-focused practice, we have two cross-linking systems operating four days per week. Treating keratoconus is a major component of our practice and one that I believe helps a lot of people.
Q: How do you view the current reimbursement climate for cross-linking?
Kevin R. Tozer, MD: In the early days, we certainly faced an uphill battle dealing with insurance carriers. Fortunately, the reimbursement landscape for iLink has improved dramatically since then. Today, we have much clearer guidelines and providers really don’t need to spend a lot of time arguing with insurance companies about coverage. We have found that working with an independent specialty pharmacy (Orsini, in our case) has alleviated much of the burden of getting under-reimbursed for the drugs used in cross-linking, and has been a huge benefit from a reimbursement perspective.
Baartman: We use the buy-and-bill method, rather than specialty pharmacy. Fortunately, we have a partner, Glaukos, that understands the reimbursement challenges and offers a variety of programs to help providers recoup some of the deficit when insurance companies don’t cover the full cost of the drug. As a practice, we have also invested time to regularly review claims and payment for each insurer so that we can identify and quickly address any problems with underpayment or claims denials. Anyone seeking to grow their cross-linking program needs to look at their financial numbers regularly. That said, I think the main challenge in keratoconus care is no longer coverage and reimbursement but getting earlier referrals, before patients have lost vision.
Parker: I agree. We almost never have claims denied anymore. In part, that’s because we have streamlined the documentation process to meet insurers’ needs. For example, our largest insurance carrier, Blue Cross Blue Shield, has a list of criteria for progression. We have a cover sheet with those exact criteria, and simply check off which one(s) have been met for the patient, with a brief explanation and/or supporting documents attached. One of the criteria is “Patient has failed contact lenses or glasses.” We always check that as a “yes,” because glasses and contact lenses aren’t a treatment for keratoconus, so of course they have failed to treat the condition. The checklist makes it very easy for the insurer to interpret.
Tozer: In a busy cross-linking practice, you do need to have someone on staff who takes ownership of and responsibility for billing and filing all cross-linking claims. We have a very experienced biller, although I think the level of experience is less critical now because reimbursement has improved so much.
Q: How have you optimized your scheduling slots and resources to maximize the number of crosslinking procedures you can do?
Baartman: I perform in-office procedures (i.e., LASIK, PRK, crosslinking) one day each week. Every Thursday, one of our two procedure rooms is fully dedicated to cross-linking, so we can perform three to four procedures that day. Because the other procedures I’m doing those days are quick, the cross-linking patient is never waiting long, and I am less likely to get behind schedule than if I were cross-linking on a surgery day or a regular clinic day.
Parker: For us, it just didn’t make sense to try to fit all crosslinking procedures into a single day. We schedule cross-linking procedures throughout the course of every normal clinic day. They take place in a dedicated procedure room that is just slightly larger than a regular exam lane. With two iLink systems, we can perform up to 10 cross-linking procedures per day.
Tozer: We use a normal exam room that also has an iLink system on one side of the room and find that incorporating cross-linking into the clinic day hasn’t been too disruptive. We like to start with cross-linking as the first appointment of the morning (7:45am) and the first appointment of the afternoon (1:00pm), with two other available slots at 10:00am and 3:00pm. That way, I am performing my longest part of the procedure, the debridement, while technicians are working up their first patients for the day. Although cross-linking takes up a room and a technician for the whole day, I honestly don’t think there is anything else I could dedicate those resources to that generates more revenue for my practice than cross-linking does.
Q: Do you track your conversion rate for crosslinking?
Berdahl: I have an aversion to that phrase and generally prefer to talk about adoption rates with something elective like premium IOLs or refractive surgery. But with keratoconus, I really don’t see cross-linking as an option we need to “convert” somebody to. It’s our mission to ensure that essentially everybody who needs cross-linking gets it.
Tozer: My surgical scheduler keeps a big spreadsheet of all the patients that I ask her to schedule for crosslinking. She basically has check-box columns for evaluation completed, specialty pharmacy order placed, pharmacy order received, patient scheduled, and procedure completed. She stays in constant communication between the patient and the specialty pharmacy to ensure that each step on the spreadsheet has happened and the drug is available in our office when needed. This has greatly improved our patient compliance or “follow-through” rate, which is so important for timely intervention in a sight-threatening disease.
Parker: We have a similar process, starting as soon as we receive a referral, before the patient is even seen in our office. Part of what we are tracking is that we have appropriate documentation of progression. There are still two barriers in successfully treating all the patients that we want to cross-link. One is that patients with high-deductible insurance plans will sometimes postpone the procedure for financial reasons. Even though cross-linking is a covered procedure, they have to meet their deductible first and may be struggling to do that. Glaukos has invested in several programs to support eligible patients on this journey with co-pay assistance or other reductions in cost. The second most common reason for declining to have cross-linking was that the patient experienced discomfort when the first eye was cross-linked. They didn’t see any better afterwards and it hurt so they don’t want to have the second eye treated. Because of this, I’ve changed how I educate patients so they aren’t surprised by this. We also now schedule both eyes for cross-linking up front so that the patient has to make the effort to cancel an appointment, rather than just put off making it.
Berdahl: We also schedule both eyes at the same time. I tell patients, “You’re really not going to like me and that’s why I have you go back and see your referring doctor first, so you can get mad at them instead of me!” Laughter is sometimes the best medicine.
Q: Tell us about the role of staff members in your success with crosslinking.
Berdahl: There is very little gray area for me on whether cross-linking is the right thing to do for someone with progressive keratoconus, and especially for a young person with keratoconus. I know it is the right thing to do. And our entire team knows that, so they work hard to make it happen. It is really uncommon for us not to be able to cross-link a patient within a couple of weeks after their evaluation.
Baartman: I agree—it really comes down to translating your passion for treating keratoconus to the team. The best thing I’ve done is share with my staff some of the more significant cases that we’ve treated in young people and the impact it has had on their lives. That way, when a front-office person is making endless follow-up phone calls or a tech is administering drops for an hour, they aren’t thinking about what a burden it is. Rather, they understand the work as an important part of saving a patient’s sight. It leads to a different demeanor and a better experience for our patients.
Parker: We have one person in the practice whose job it is to get the records from every eye doctor the patient has ever seen and sift through them for the data we need to document progression of keratoconus. At various times, this role has been filled by a technician or by a front-office staffer. What is most important is for that person to have a “stick-to-it” attitude and be extremely persistent in following up on missing information. With this approach, I already know whether there is evidence of progression or if that evidence does not exist before the patient walks in my door.
Baartman: We started doing exactly the same thing. Historically, we would get a referral, schedule the consultation, and then struggle to get all the documentation lined up prior to performing cross-linking. Now, I’m able to focus all of my energy in the limited time I have with the patient on educating them about keratoconus, what to expect from cross-linking, and why they need the treatment. It definitely takes a team to make a keratoconus program really click.
Q: How have you built your optometric referral network?
Tozer: I initially focused on marketing the service to optometrists who fit scleral lenses, because they see the most irregular corneas and are more likely to pick up keratoconus. But the reality is that the franchise practices and big commercial chains see a large volume of patients, so you really can’t ignore those practices if you want to catch patients with early-stage keratoconus.
Parker: I agree. I have found it surprisingly unpredictable who will be the best referral sources. There are some advanced scleral lens fitting practices that never send us anybody, and there are some big-box retail practices that send five patients a week. So we need to let everyone know that cross-linking is available. I give talks about keratoconus several times each month to doctors in the community, and I have personally visited most of the independent optometrists within a few-hour radius of my practice. And the truth of the matter is that people send me patients mostly because I asked them to. I don’t give them a lot of complex criteria for who I do and don’t want to see. I just say, “If you have a patient with keratoconus, or you are worried they might have keratoconus, please send them to me for a cross-linking evaluation.”
Baartman: Personal visits have made a big difference in building my practice, as well. I would simply ask, “Who are you currently referring to for cross-linking?” and the most common answer was, “No one.” I found that many doctors really didn’t know much about keratoconus or they thought the treatment was experimental and didn’t realize that iLink had been approved by the FDA. Over time, I think this will change. There are programs to help optometrists acquire topographers for their offices now. New optometrists coming out of school will also have been exposed to the iCKC program, a joint effort by the Optometric Cornea, Cataract, and Refractive Society (OCCRS) and Glaukos to educate future doctors about modern keratoconus diagnosis, monitoring, and treatment. By visiting doctors in person, we can also educate while building relationships. You also have to be willing to eat the cost of some tests and clinic time when a referral practice sends you a normal patient who just has high cylinder. There’s no code to bill for “keratoconus suspect” if it turns out they don’t have the disease. But I tell optometrists I would rather have that happen than miss a true case of keratoconus.
Berdahl: I agree. The most important thing is to get patients in the door so that we can do the right thing for them. We tell referring optometrists that we’ll sort out the insurance side of things, and we don’t do any pre-authorization or pre-determination before they come to our office. We don’t want there to be any barriers to the consultation. I’ve also had good success in sharing an eye rubbing video with our optometric network. It captures people’s attention and sticks in their memory. That has gotten optometrists to start asking their patients, “Do you rub your eyes?” We want those patients to stop rubbing their eyes anyway, and it raises the suspicion of keratoconus when the doctor knows the patient has that habit.
Tozer: Another huge referral source is our keratoconus patients themselves. Family members are up to 67% more likely to have keratoconus than a person who doesn’t have a first-degree relative with the disease.1 We offer keratoconus screening exams for family members that include topography and tomography and, if those are normal, a genetic screening test.
Q: What do you see for the future of cross-linking in your practice?
Tozer: It will continue to grow. We are just beginning to see great improvements in visual rehabilitation for patients with keratoconus, with technologies like topography-guided PRK and small-aperture IOLs. But cross-linking to stabilize the cornea first is really the cornerstone technology that allows any of those things to be successful. I think we can envision a future in which there are no more penetrating keratoplasties for keratoconus.
Berdahl: Absolutely. And that’s great news for all our patients with progressive keratoconus, but especially for those really heart-wrenching cases, such as kids with Down syndrome who would otherwise progress to needing a corneal transplant that would be really hard on their whole family. We have already come a long way down the road of improving care for keratoconus, but I think we still have an interesting journey ahead as we see where cross-linking can take ophthalmology practices and our patients.
Gordon-Shaag, Millodot M, Shneor E, Liu Y. The genetic and environmental factors for keratoconus. Biomed Res Int 2015;2015:795738.