The greatest eye doctors have devoted their careers to learning about and caring for the visual systems of their patients, expanding their scope of care and expertise over time as optometrists have expanded their skills and knowledge base to include more systemic care.

As much as eye care professionals love to learn, we’re confident that none of them became optometrists to wrestle with confusing insurance paperwork or red tape. We’re likewise pretty sure that nobody became an optician to send claims to an insurance company only to see them get denied or rejected at every opportunity.

Fortunately for eye care providers everywhere, there are experts who love digging into the specifics of policies and working to understand how to maximize patient care within the confines of an insurance company’s rigid framework. Unfortunately, vision insurance and medical insurance have become simultaneously more complex and more restrictive over time.

In this article, we’re going to discuss some of the complexities faced by billers and coders at practices like yours across the country. If your goal is to run a successful practice, provide the highest level of care and to help your patients take full advantage of the benefits to which they have access, then read on!

Anagram’s RCM team has decades of experience in optimizing cash flow and educating providers to improve every facet of the billing process. We understand that your billing team has a lot on its plate and know exactly what the pitfalls are and where they might be found.

Your billing staff must stay current with changes in vision insurance policies, coding standards, and regulatory requirements which will involve regular training sessions. It takes ongoing effort to stay up to date with industry best practices and to ensure that the billing process is efficient and compliant.

Since the billing department, by nature, collaborates with other departments, especially the front desk and clinical team, the rest of the practice must have at least a baseline understanding of the billing and coding process to ensure accurate coding, patient education, and coordination of benefits. Staff training may include understanding the workflows and challenges of these other departments.

Taking a broader view of your billing department and its impact on your business requires understanding that billing is a component of revenue cycle management rather than the entirety of it. Accurate claim submission, strong compliance, ongoing staff training, and diligent education are all parts of what separate a successful billing organization from a struggling one.

Claims Submission

This is the bread and butter of medical billing teammates in eye care practices across the country; where the products sold and services rendered meet the financial side of your business. Your entire clinical and financial operation should have at least a baseline understanding of and agreement on how this process ought to work.

Coding and Documentation

Among the many critical tasks accomplished by your billing team perhaps none are more important to your cash flow as their role as your practice’s first and last chance to verify that all services provided are accurately coded in your system of record. That means using the correct CPT (Current Procedural Terminology) and ICD (International Classification of Diseases) codes, which itself means staying current with the current state of those codes.

For most practices, Coding is actually done by the OD or the Software, and then confirmed by the OD. Both major medical and vision insurance companies have specific requirements for these codes, inaccuracies or improper coding can and will lead to claim denials, rejections, and delays. Documentation is also essential to support the services billed, and it must align with the codes used.

Claim Form Preparation

Whether handwritten, printed, or submitted electronically using appropriate claim forms like the CMS1500, claims must be meticulously prepared prior to submission to the insurance company.

As a minimum expectation, each claim must include the patient’s insurance details, provider information, services rendered, and associated costs; but it’s important to understand that even if the information provided is perfectly accurate, claims can still be denied or rejected for more clerical reasons. Misprinted claims, a crossed-out line of text, an illegible signature, or single piece of information can render the claim unusable, causing frustration and delays.

Billing Software / Electronic Claim Submission / Clearinghouses

The data quality in your Practice management software and how well it integrates with electronic health records (EHR) helps your team effectively manage the billing process from claim submission to payment tracking and everything in between. It must be regularly updated and the training around it refreshed to accommodate changes in coding standards, insurance requirements, and billing regulations.

Insurance companies can require or prefer electronic claim submission, and it’s likely to your practice’s advantage to become well-versed in using software where possible to make your RCM process more accurate and easier to perform, repeat, audit, and measure.

Timely Reimbursement

Insurance reimbursements by nature, take longer to realize than direct patient payments do, which certainly impacts your practice’s top and bottom lines. Part of your RCM organization’s process should revolve around optimizing the revenue cycle so that claims are submitted promptly and followed up as needed to expedite payment.

Tracking and Follow-Up

Once claims are submitted, someone in your billing department should track their status throughout the process to ensure that the appropriate actions are taken when they are rejected, denied, paid, or partially paid.

Sometimes this follow up requires direct communication with the insurance payor or clearinghouse, sometimes there are steps the billing team can take directly to correct errors and resubmit claims without further delay. Having a clear understanding of what to do and when is critical in the successful operation of your in-house revenue cycle management team.

Handling Denials and Appeals

Wouldn’t it be great if once a claim was filed, the insurance company would take it from there and issue reimbursements smoothly and without complications? Unfortunately, we often see claims denied for increasingly opaque reasons, and when this occurs, your practice is left with three primary options, laid out below.

Denial Management

Common reasons for claim denials include coding errors, lack of medical necessity as dictated by the insurer, missing documentation, duplicate claims, or filing for non-covered services under the patient’s insurance plan. When a submitted claim is denied, your billing team should jump into action to correct the issue and resubmit the claim or file an appeal as quickly as possible to ensure the claim is submitted before the timely filing deadline passes.

Appeal Process

If your practice disagrees with a denial (e.g. because a service should be covered by the plan or the procedure is in fact medically necessary), the billing department may initiate an appeal. This process requires a deep understanding of medical documentation and insurance policies; filing appeals can also be time-consuming and might require gathering additional documentation, writing appeal letters, and possibly coordinating with the patient or provider to justify the services rendered.

Depending on the services rendered for which your practice is filing an appeal, it may be beneficial to reconsider chasing these reimbursements in the future if the cost of doing so outweighs the benefit.

Balance Write-Off

After your practice has sought recourse and submitted and resubmitted claims and appeals to no avail, you may decide it’s in your best interest to simply write off the balance from your Practice Management System and chalk it up as a lesson learned.

This is an unfortunate but all-too-common result when your revenue cycle management team is in-house, has a million other things to worry about, and can’t devote the time to collecting every dollar owed from insurance companies that spend a lot of time and resources denying claims.

Patient Billing and Communication

Vision and medical insurance often involves copays and deductibles as part of patient responsibilities. Accurately calculating and collecting these amounts is key to properly setting patient expectations and fulfilling your contractual obligations to the payors with which you have a signed agreement.

This understanding allows your practice to provide clear communication to the patient about their insurance coverage and likely out of pocket expenses.

Patient out-of-pocket costs arise for services submitted to but not covered by insurance, or if the patient’s benefits have been exhausted, your practice must receive payment directly from the patient, in which case sending bills (or invoices or statements) to the patient and following up with consistency.

Working to ensure patients understand their financial obligations and to minimize disputes is among the more emotionally fraught aspects of revenue cycle management and as such can be one of the most challenging.

Coordination of Benefits

While this does not generally apply to vision insurance patients, an increasing number of patients have multiple health plans that may require your RCM team to bill in a particular order, verify that all services are available under all plans, and other highly contextual and specific minutia.

How your team handles these patients certainly affects your top and bottom lines, but also can have huge reputational implications if a patient disagrees with how COB is handled and decides to be vocal about it.

If a patient has more than one insurance plan, the billing department must understand how to coordinate benefits between the primary and secondary insurers. This includes determining the order of payment, ensuring that claims are submitted to the correct insurer first, waiting for the appropriate amount of time to pass or receiving acknowledgement that the initial claim has been received before filing to the patient’s secondary, and handling any balance billing issues that arise.

This process, like most as it relates to revenue cycle management, requires careful tracking and follow through to ensure that all payments are received and correctly allocated and no outstanding balances linger in the patient’s record after COB has been completed.

Insurance Contract Management

In some higher volume practices, the RCM team lead can handle the actual negotiation of insurance agreements up to and including reimbursement rates, panel credentialing, covered services and billing rules.

With respect to vision and medical insurance agreements, a practice’s ability to negotiate improvements in its terms is largely predicated on its position at the time of negotiation. For example, a high-volume practice serving a lot of patients from a particular insurer is on better negotiation footing than a cold-start practice with no patient base to leverage in negotiation.

At the very least, the billing department must be familiar with the agreements between the practice and the various contracted medical vision insurance companies. These contracts govern the reimbursement rates, covered services, and billing rules.

These responsibilities often extend to partnering with the practice leadership to determine which insurance plans to renew agreements with, which ones to add, which ones to subtract, and which ones to let lapse at the end of the term.

Financial Reporting and Analysis

The billing department is responsible for tracking payments from insurance companies and reconciling these payments with the services provided. This includes identifying any discrepancies between what was billed and what was paid, and addressing these discrepancies.

This element of revenue cycle management provides essential data for financial analysis, helping the practice understand how much revenue is generated from insured patients versus out of pocket payments as compared to private pay or cash-pay patients.

It is nearly impossible, or at the very least very difficult, to effectively pursue outstanding claims if payments aren't posted accurately.

More than just identifying whether or not a given insurance provider has been an effective partner for your practice, these analyses can (and perhaps should) inform decisions on service pricing, participation in insurance networks, and overall financial strategy.

Compliance and Audits

Medical and vision insurance companies may conduct audits of the practice’s billing records to ensure compliance with their policies and federal regulations; the terms and scope of these audits are outlined in the credentialing agreement and it’s critical that your entire team understands the implications of having an unsuccessful audit as a result. As a minimum expectation, your practice must maintain accurate and complete records to pass these audits and avoid penalties or repayment demands.

HIPAA (Health Insurance Portability and Accountability Act) and related regulations must also be taken into consideration throughout your practice’s operation. For your RCM team this includes but is not limited to safeguarding patient data during claim submission and in all communications with insurance companies and patients.

Conclusion

Any successful revenue cycle management/billing department will have to learn to become experts in navigating complex processes related to claims submission, denial management, patient billing, and insurance contract compliance.

If your practice is working toward or has already achieved more of a medical model of practice, then the immediate financial health of your practice is heavily dependent on a strong RCM team at your disposal.

Things like ensuring timely reimbursements, mitigating denials or rejections, and providing clear communication with patients are what separates an effective RCM team from a problematic one. Which would you rather have working in your practice?