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Archive April 2020 XXI, No. 4

Don't Pass Up Pass-Through Payments

Understanding the billing process will ensure your cataract patients have access to new and innovative medications.

Lisa Nijm

Lisa Nijm, MD, JD


INNOVATIVE MEDS Ophthalmic drugs improve patient care, but their pass-through funding status can be cumbersome to navigate.

Ohthalmology has a long history of innovation, and we're fortunate to have access to several cutting-edge treatments that reduce pain and inflammation after cataract procedures, thereby reducing the need for post-op eyedrop therapies.

  • Omidria (1 % phenylephrine and .3 % ketorolac) is an irrigating solution administered with balanced saline solution during surgery to maintain pupil dilation and reduce post-op pain. It costs about $465 per case. Omidria's pass-through status expires on Oct. 1. Lobbying efforts by the product's manufacturer could result in another new pass-through period or establish a permanent separate reimbursement.
  • Dextenza is a corticosteroid insert placed by the surgeon to treat post-operative pain by delivering a tapered dose of dexamethasone for 30 days. It costs approximately $572 per insert with a pass-through status that runs until the end of 2021.
  • Dexycu (dexamethasone) 9% is an extended-release steroid delivered with a single injection that is designed to decrease post-op inflammation. It costs about $696 per case and its pass-through status also runs until the end of 2021.

These medications can decrease the usage of postoperative drops, thereby decreasing the need for patient compliance and improving outcomes.

The significant price of these medications makes them cost-prohibitive in a specialty with slim profit margins, but the pass-through status lets your facility bill Medicare separately for the per-case cost plus 6%.

Congress created pass-through payments to ensure innovative new drugs, devices and biological agents are available for patients and paid for separately from a facility's or physician's bundled payment. While the cost may seem large relative to the facility fee, this is a mere fraction of what CMS has set aside for pass-through products. CMS, not the drug manufacturer, determines the price of these medications through a complex formula that they use for all pass-through products.

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