Establishing Benchmarks for Glaucoma Testing

A large management services organization (MSO) with practices across several states was seeking to set standards for ophthalmologists in all of their locations to ensure alignment of glaucoma testing across the enterprise.

Situation

The organization sought to establish an enterprise-wide standard of care for common glaucoma types—primary open-angle glaucoma and glaucoma suspect—by developing annual diagnostic testing benchmarks for patient evaluations. To achieve this, they required a custom utilization analysis (UA), thorough review of billing and coding practices including an understanding of the American Academy of Ophthalmology (AAO) published practice patterns, and ongoing chart audits and training.

Solution

The client engaged VMG Health to conduct a customized analysis targeting glaucoma testing with a detailed and focused approach. VMG Health then analyzed Medicare policies and the Preferred Practice Patterns published by the AAO to set specific benchmarks for the organization. Based on the published standards, VMG Health determined that several providers were ordering diagnostic tests well below the benchmarks leading to missed revenue opportunities. Following the detailed analysis, the VMG Health Ophthalmology team provided education and training to organizational staff and providers to communicate the new testing benchmarks, establish an enterprise standard of care, and capture any increases in reimbursement. After giving the providers several months to implement the training, the VMG Health Ophthalmology team performed a series of chart reviews, starting with the highest volume glaucoma providers, to track changes in testing frequency.

To evaluate the efficacy of the changes implemented by VMG Health, the consultants serving the organization will return to provide ongoing support and conduct a secondary, custom UA.

Success

VMG Health found that the organization’s utilization of glaucoma testing was below the benchmarks. After applying the benchmarks, the estimated revenue increase from performing the expected number of glaucoma tests was between $700,000 and $800,000 annually. Ensuring all of the organization’s providers adopted these standards was crucial for realizing this revenue. Small exceptions or limitations related to physician resistance and/or equipment accounted for range.

Because of the organization’s need for ongoing support, VMG Health will continue tracking testing frequency and practice patterns over time to gather sufficient data for meaningful analysis. The follow-up process involves reviewing the data gathered, documenting improvements, and addressing further challenges.