The matter of co-managed care

February 1, 2008

Co-management has come under fire from the federal government because of some instances of serious abuses. It can succeed when done correctly, however.

Key Points

Reider recently spoke about the rules and government concerns during the past two decades in a presentation, "What's New in Co-Management?" He began with some historic background, recalling, "The first time I was asked to speak on co-management was in 1986. I said, 'Sure, I'd be happy to. What's co-management?'"

Initial guidance from the federal government on co-management came in 1994. An attorney for the Office of the Inspector General (OIG) said in the American Medical Association newsletter that an agreement to refer patients could be a violation of the anti-kickback statute, or quid pro quo.

Instead of granting safe harbor status, the government said it would make decisions on a case-by-case basis to determine whether problems existed, such as an agreement to refer and a potential violation of kickback statute.

"I happen to agree that this is an absolutely correct decision," said Reider. "Co-management can be done correctly, but I happen to agree with the federal government that there can also be some serious abuses. It becomes very, very important for us to understand what kinds of facts the government is concerned about when looking at co-management relationships."

Trickle-down politics

Reider outlined some state-level initiatives from 2001-2002. Legislation that he described as very restrictive regarding co-management failed to pass in Florida and Missouri. A co-management law was passed in 2001 in Nevada, however. That law, Reider said, is not restrictive and serves as a guideline.

"Nevada says it is absolutely legal to co-manage if there is written documentation from the surgeon and co-manager," he said.

The law says that fees must be divided in proportion to services performed by each individual practitioner. In addition, specific written documentation is required, including a statement signed by the patient that explains fees and postop care options.

In 2000, several professional societies published tenants relating to co-management that generally were consistent, Reider added.

"In 2003, the OIG issued a work plan that said, 'This is what we're looking at: potential issues with cataract surgery co-management,'" he said. The OIG was interested in billing problems and the use of modifiers, he added. Also that year, the OIG issued a subpoena for its first serious investigation of co-management.

Before discussing the specifications of the subpoena, Reider said, "I've always promoted patient choice as being critical. It is the decision of the patient to return to the co-managing optometrist, not the decision of the ophthalmologist or optometrist."

The subpoena specified what was to be provided to the investigators, Reider said. The first section asked for documentation pertaining to patient records.

"Here, for the first time, is a reference to patient choice," he said. "This is exculpatory evidence."

The next section asked for documents relating to an agreement or contract to co-manage care. A written agreement to refer never should exist, Reider said.

Other specified documents included information relating to yearly budgets and projections relating to referrals. Again, Reider suggested not maintaining documentation that deals with the number of referrals on co-managed patients.