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Medicare

Medicare is the largest payer for ophthalmology in America. The Academy fights every year to ensure payment policies are fair, accurate, and sustainable.

Ophthalmologist examining a patient

Medicare sets the financial foundation for ophthalmology practice in the United States. Cuts to Medicare physician reimbursement also affect Medicaid and commercial payer rates, which often benchmark against Medicare — disproportionately impacting small, independent practices serving rural and underserved communities. From the annual physician fee schedule to the rules governing Medicare Advantage plans, Medicare payment policy determines how — and whether — ophthalmologists can continue to deliver high-quality surgical and medical eye care to the patients who depend on them most. 

The stakes are high and the threats are persistent. The Medicare physician fee schedule conversion factor has declined in real terms for decades. Budget neutrality requirements mean that increases in certain services trigger cuts to others. Medicare Advantage plans impose prior authorization requirements, downcode claims, and deny reimbursement at rates that exceed traditional Medicare. And audit programs targeting modifiers like modifier -25 create compliance burdens that consume physician time and resources without improving care. 

The Academy engages on every front — through annual rulemaking comments, coalition advocacy with the AMA and the Surgical Coalition, direct congressional engagement, and targeted action against individual payer abuses — to protect the Medicare payment environment that ophthalmology and its patients depend on. 

Medicare Advantage

Medicare Advantage plans are delaying and denying care for ophthalmology patients through prior authorization, step therapy, and other administrative hurdles.

Medicare Physician Fee Schedule

The Academy works to ensure Medicare's annual physician fee schedule delivers fair payment to ophthalmologists for the care they provide.

Medicare Physician Payment Reform

Decades of inadequate Medicare payment updates threaten ophthalmology practices' ability to serve patients and preserve their sight. 

Modifier -25

Federal audits and limited guidance from the Centers for Medicare & Medicaid Services (CMS) threaten ophthalmology practices that appropriately bill same-day evaluation and management (E/M) visits with intravitreal injections.

Global Surgical Payment

Medicare's global surgical payments are a bundled reimbursement that cover all necessary services associated with a surgical procedure in a single fee. Due to changes in CMS policies, the Academy and the Surgical Coalition believe ophthalmologists and other surgeons are not being fairly compensated for the post-operative care included in global surgical payments.

Defend Medicare Payment for Eye Care

Medicare payment rates affect nearly every ophthalmologist. When CMS proposes cuts or Congress acts, your voice matters. Stay informed and engaged.

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Latest News

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Milestone Moment: Seniors' Act Advances Unanimously Through Ways & Means Committee

Thanks to Academy advocacy and leadership, and the voices of members like you, the Seniors’ Act cleared a major hurdle in reforming prior authorization in Medicare Advantage. Let’s keep pushing until it becomes law.

Member exclusive
Intravitreal Injection

Ophthalmology Groups and AMA Urge CMS to Clarify Modifier -25 Use for Intravitreal Injections, Pause Audits

Here’s the latest in our push for CMS to fix conflicting coding guidance that could limit Medicare patients' access to critical retinal treatments.

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Medicare Physician Pay 101: The New System’s Impact on Your Payments

New system comes with new bonuses and penalties as a means for emphasizing value over volume in patient care

Our Advocacy in Action

The Academy works year-round — through rulemaking, coalition advocacy, and direct congressional engagement — to protect and improve Medicare payment for ophthalmologists and their patients.

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