This position paper examines the role of co-management of ophthalmic surgical patients and offers guidelines as to when this practice is ethical and proper and when it is unethical and even illegal. Co-management will be defined as the sharing of postoperative responsibilities between the operating surgeon and another healthcare provider.

Federal Medicare policy concerning co-management has been adapted and interpreted by States and carriers with variations in details and restrictions. In addition, the AMA and the American College of Surgeons have issued guidelines addressing this issue, agreeing that the operating surgeon has the responsibility for the postoperative care and disapproving if economic considerations drive the decision to transfer the care of a patient following surgery. Although this obligation may be ethically ceded to another healthcare provider, it is anticipated that this will be an exceptional, rather than a routine, occurrence. If the reason for sharing postoperative care with another provider, however well trained, is economic, specifically as an inducement for surgical referrals, or the result of coercion by the referring practitioner, it is patently unethical and, in many jurisdictions, illegal. The Office of the Inspector General of the Department of Health and Human Services has also expressed concern about co-management based on economic considerations rather than clinical appropriateness and has refused to provide safe harbor protections for such arrangements, preferring to review cases on an individual basis.

If co-management of surgical patients is being considered, justifiable circumstances should exist such as:

• The surgeon’s unavailability (travel, illness, leave, itinerant surgery in a rural area, or surgery performed in a designated physician shortage area).
• The patient cannot travel to the surgeon’s office because of distance or the development of another illness.

When situations arise in which the surgeon concludes that the delegation of postoperative care is in the patient’s best interest, guidelines that should be followed include:

The surgeon, prior to surgery, must inform the patient if there are any prearranged postoperative management plans, and the patient must voluntarily consent to this in writing. This consent process, which should be documented in the medical record, should include the reason for the transfer of care, the qualifications of the healthcare provider who will render the postoperative care, and any special risks that may result from this arrangement.

• If an unanticipated transfer of postoperative care is required, the patient should be informed and this information documented in the medical record.
• The surgeon should inform the patient of the financial implications resulting from the co-management arrangement, particularly with regard to the patient’s payment obligations and the postoperative provider’s reimbursement.
• The transfer of care must not occur unless it is clinically appropriate and in the patient’s best interest.
• The surgeon should confirm that the co-manager is legally entitled and professionally trained to provide the particular services.
• The co-management must not be done as a matter of routine policy on all patients.
• The surgeon should follow the patient until postoperatively stable, and there is no fixed time when the patient is sent back to the referring provider.
• The patient should be reassured that he/she has access to the surgeon, if necessary, during the postoperative period at no additional cost. (If a Medicare/Medicaid patient returns to the surgeon, both the surgeon and postoperative care provider must file a corrected claim.)
• Any fees must reflect an appropriate fair market value for the services performed.

The American Academy of Ophthalmology and the American Society of Cataract and Refractive Surgery agree with the above positions. The ophthalmic surgeon has the primary responsibility for the preoperative assessment and postoperative care of his/her patients, regardless of the type of surgery performed. The decision to co-manage should be the result of a determination of what is best for the patient and not economic considerations. If the co-management of patients is done on a routine basis for predominantly financial reasons, it represents unethical behavior and may be illegal. Above all, patients’ interests must never be compromised as a result of co-management.

*This position paper is provided for informational purposes and is intended to offer practitioners voluntary and non-enforceable guidelines as to what co-management practices the AAO and ASCRS consider to be appropriate and in patients’ best interests. Practitioners should use their personal and professional judgment in interpreting these guidelines and applying them to the particular circumstances of their individual practice arrangements. This paper is not intended to provide legal advice and should not be relied upon as such. Practitioners are encouraged to consult an experienced health care attorney if they have questions about the propriety of their co-management arrangements under applicable laws and regulations.

Approved February 2000