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Denial Management for Optometry Providers

Denial Management for Optometry Providers

A rise in cash flow and enhanced processes will improve the efficiency of the billing process, which comes merely with timely and effective denial management. In no small measure, in the world of medical billing, the rejection of claims is a significant cause of annoyance and declining profits for doctors and a myriad range of healthcare providers. Thus, it is crucial for practices to pinpoint the causes, stop them from circling, and choose strategies that will help them become more financially and strategically functional.

Squaring closer to optometry billing, the processes are integrally tied to claim administration and reimbursement, and these are frequently seen by optometry professionals as being very difficult and time-consuming jobs. It’s really not their fault, is it? After all, these complex tasks are supposed to be taken care of by the medical billing companies.

Optometry billing procedures present a unique set of difficulties, most of which are connected to claim administration and payment. These difficulties act as hurdles for the optometrists and ophthalmologists from maximizing their income cycles. This is the sad truth, however the best part is that this can be avoided. Firstly, let’s glance through the common denial reasons, shall we?

A listicle of common denial reasons and their solutions

1. A claim for the same service or procedure is submitted twice: Always check with the insurance payer first since they might be processing the claim before submitting an unpaid claim. Find out what is the root reason as to why the claim was denied or why it wasn’t paid.

 2. The patient’s health plan coverage expires, they are not eligible for services: The inhouse team should always verify coverage by looking at the patient’s insurance. In order to be sure you have the correct claims filing address and other crucial information, make a copy on both sides of the patient’s insurance card.

3. The doctor is not a part of the provider network: Verify if the insurance company has given the provider their approval. Provider credentialing documents should be submitted and tracked depending on insurance plan criteria. When enrollment is available, make sure the providers are enrolled in-network by following up with insurance payers frequently.

4. Incomplete or incorrect patient demographic and insurance data: Verify the patient’s name, date of birth, responsible party, and vision and medical plan numbers to make sure they are all spelled correctly. A denial will result from even one necessary field.

5. The benefit involves more visits or services than are permitted: Always check with the insurance payer to make sure the patient is eligible. Numerous insurance companies limit the amount of visits or treatments that can be covered in a given year.

6. There is a need for a prior authorization number for the claim: An important first step in the RCM process is to confirm a patient’s insurance benefits. Whenever feasible, get the insurance payer’s approval before the patient visits. Verify the prior permission number is written on any claim before submitting it.

7. Either a code or modifier is missing from the claim, or the modification is invalid: If even one of the procedure codes does not match the modifier being utilized, or if a mandatory modifier is not present for the date of service being billed, payers will reject your claim. Never, for instance, assign modifier 59 to an E&M service.

Depending on the local regulation, you might be able to link the correct diagnosis and procedure code and add modifier 59 to the second procedure if the tests are required owing to two independently recognized conditions.

8. Instead of bundling services, the bills should have been issued separately: Some services, such as laboratory profiles with several tests or an all-inclusive cost that includes the minor procedure and the pre- and post-operative visits, cannot be claimed separately and may need bundling.

9. The POS does not correspond to the action taken: Change the CPT code, then submit the claim again. Make sure that the POS corresponds to the location of the face-to-face service the patient received or the location where the technical part of the service was provided.

10. The service is not medically necessary or is not covered by the plan’s coverage: For a list of covered diagnoses, consult your Local Coverage Determinations (LCD) policies on the website of the insurance payer.

Wrapping Up

Post the pandemic, optometrists have seen significant changes in the way they conduct business. Outsourcing optometry billing services tops the list of their efforts regarding claim management and reimbursement due to the impact of COVID-19 on insurance coverage! This is a smart move given the stemmed fact that they do not have the right skills and advanced technology to toss away the lingering challenges and bring solutions to the table.

At Medisys Data Solutions, we understand that it can be challenging for optometrists to enhance denial management due to a lack of knowledge on various amendments to rules, regulations, and laws pertaining to optometry medical billing services. Without the assistance of a medical billing professionals, the process of medical billing is a challenging subject to comprehend and it may be challenging to stay current with changes in this field. Fret not, we have got your back!

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