Left to Right as you look at photo: Walter Choate, OD, his wife Deborah, Diane Godwin (Jerry Godwin’s wife) and Jerry Godwin. Dr. Choate is a client of Godwin’s company, OMS. Godwin has worked with Dr. Choate to find ways to serve patients better while increasing reimbursements.
Charge capture audit for ODs
Part two of a three-part series exploring why ODs are often not reimbursed as they should be. Click HERE to read part one.
By Jerry Godwin
March 12, 2025
In part two of our three-part series, “Why am I not getting paid for the claims I am filing,” we’re diving into the claim workflow and the technical challenges hurting your bottom line.
We call this evaluation process the Charge Capture Audit. This process starts at the patient check in and goes all the way through reimbursement, examining each step to see if there is revenue leakage.
According to the Healthcare Financial Management Association (HFMA), the average medical practice loses $125,000 annually to poor charge capture processes.
From duplicate claims to misused modifiers and submission errors, we’ll explore how these issues impact your bottom line, and most importantly, how to fix them.
On top of discovering where revenue leakage might be occurring in your practice, this process will also help you maintain compliance with healthcare regulations, mitigate your risks and improve overall operational efficiency.
Let’s dive into the claims workflow and identify common mistakes, their impact and how to fix them.
1. Incorrect Coding (CPT, ICD-10, HCPCS)
Why it Happens: Coding errors occur when staff rely on outdated code books or select incorrect codes from EHR recommendations. In many cases, incomplete documentation leads to incorrect coding decisions.
Impact: Coding errors lead to claim rejections and can trigger payer audits, resulting in significant payment delays or penalties.
How to Fix It:
- Provide Comprehensive Training: Train yourself and the team on the latest CPT and ICD-10 coding updates and payer-specific rules. Consider using a routing slip that includes commonly used codes, patient financial details and other essential information to ensure accurate documentation for proper coding. Many practice management systems offer a similar feature, but if yours does not, a paper version can be just as effective.
- Conduct Regular Audits: Review a sample of submitted claims monthly to identify and correct recurring coding errors.
- Utilize Technology: Invest in coding software where you can research and keep current with coding changes. Also, consider using code scrubbing software.
- Address Issues Immediately: Submit corrected claims quickly and address training issues to avoid recurring problems.
2. Missing or Misused Modifiers
Why it Happens: Modifiers are frequently missed or applied incorrectly, usually because staff are unfamiliar with payer-specific guidelines or how to interpret documentation properly.
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Impact: Misused modifiers result in rejected or underpaid claims, particularly for procedures like post-operative care or surgical procedures.
How to Fix It:
- Proper Documentation & Training: Train your team annually on the modifiers available, their usage and proper documentation to support their usage.
- Create a Modifier Guide: Develop a quick-reference guide for commonly used modifiers specific to eyecare services and payers.
- Integrate Modifier Checks: Use EHR tools that prompt staff to verify modifiers during claim submission, and review denials regularly to identify patterns of incorrect modifier use.
3. Duplicate Claims
Why it Happens: Duplicate submissions often occur due to manual workflows or confusion about whether a claim was previously sent.
Impact: Duplicate claims lead to unnecessary denials and can complicate payer relationships.
How to Fix It:
- Track Claims in Real Time: Implement software that tracks claim submissions and flags duplicates before they reach payers.
- Centralize Communication: Ensure all billing staff documents claim submission statuses clearly in your practice management system.
- Correct Claims Promptly: Review claim status and verify correct claims were submitted with appropriate re-submission code.
4. Claim Submission Errors
Why it Happens: Simple mistakes, like missing required fields or incorrect payer details, result from rushed processes or lack of oversight.
Impact: Errors at the submission stage lead to outright rejections, delaying payment by weeks or even months.
How to Fix It:
- Utilize Reporting Systems: Review the rejected claims report or internal tracking to ensure all claims have been filed and received by the payer.
- Use Submission Checklists: Develop a standardized checklist for claim submissions to ensure all required information is included.
- Automate Where Possible: Leverage clearinghouses that validate claims before they’re submitted to payers.
5. Clearinghouse Issues
Why it Happens: Clearinghouses sometimes incorrectly route claims or fail to provide detailed feedback on rejections.
Impact: Miscommunication or processing delays result in prolonged payment cycles.
How to Fix It:
- Evaluate Clearinghouse Providers: Choose a clearinghouse with robust support and real-time dashboards.
- Clearinghouse Set Up: Accurate Electronic Data Interchange (EDI) enrollments are essential for seamless claim filing, receiving payment advices and verifying benefit eligibility.
- Monitor Performance: Track clearinghouse rejections and escalate issues promptly to ensure quick resolutions.
6. Late Submissions
Why it Happens: Practices often miss payer deadlines due to disorganized workflows or a lack of knowledge around different filing deadlines.
Impact: Late claims are denied outright, and some payers penalize for late submissions.
How to Fix It:
- Set Reminders: Use automated calendar reminders to flag approaching deadlines.
- Streamline Documentation: Standardize workflows to ensure claims are submitted promptly after services are rendered.
- Review AR Monthly: Consistent AR reviews help prevent missed filing deadlines and empower your team to improve payment collections.
- Confirm Payer-specific Filing Timelines: Every payer has their own deadlines making it important to track and note each deadline.
7. Un-bundling or Bundling Mistakes
Why it Happens: Staff misunderstand payer rules about which services should be bundled versus billed separately.
Impact: Incorrect bundling results in denied claims or underpayments, particularly for surgical procedures (i.e.: Foreign Body Removal codes). For example: Cataract co-management claims must be billed with an appropriate 55 modifier to show co-management of the claim. Using a 25 modifier with an exam code should meet the criteria as being “defined as a significant, separately identifiable Evaluation and Management (E/M) service by the same physician or other qualified healthcare professional on the same day of the procedure or other service.”
How to Fix It:
- Audit High-Risk Claims: Regularly review claims for procedures prone to bundling errors.
- Create Payer-Specific Rules: Maintain a database of bundling guidelines for your top payers and train all clinical staff.
8. Failure to Track Claim Status
Why it Happens: Busy teams often submit claims and fail to follow-up until they receive payment or a denial.
Impact: Un-tracked claims can linger in processing or be denied for avoidable reasons.
How to Fix It:
- Adopt Claim Management Tools: Use platforms that offer real-time claim tracking and status updates.
- Assign Ownership: Designate a team member responsible for monitoring claim statuses and following up promptly.
9. Mismanaged Write-Offs
Why it Happens: Practices may write off claims prematurely due to confusion about payer policies or lack of follow-up.
Impact: Overuse of write-offs represents significant revenue loss.
How to Fix It:
- Track Write-Offs by Reason: Categorize and analyze write-offs to identify patterns and prevent avoidable losses.
- Create a Write-Off Policy: Establish clear guidelines on when and why claims should be written off.
10. Practice Management Software
Why it happens: Inadequate staff training can lead to coding or data entry errors. Software can also have glitches that can impact the revenue cycle.
Impact: Errors in patient information, coding or claims submission can cause delays, denials and lost revenue. Some outdated or inefficient software lacks automation, slowing down billing and collections. If reporting features aren’t used effectively, providers may miss out on key insights that could improve claim success rates.
How to Fix It:
- Ongoing Training: Ensure staff receive thorough and ongoing training on the practice management system to minimize data entry and coding mistakes.
- Regularly Update Software: This ensures you benefit from the latest features and security patches.
- Review Reporting & Analytics: Keeping a tab on the numbers allows you to identify trends, spot problem areas and optimize revenue cycle performance.
11. Poor Team Communication
Why it Happens: Healthcare is a high-pressure work environment, and without clear processes in place, communication gaps can easily occur. Language barriers, inconsistent documentation and lack of coordination between billing, front desk staff and providers can create costly mistakes.
Impact: Poor communication can result in claim denials due to incorrect patient information, missing documentation or misfiled codes. It can also lead to delays in claim submissions, payment posting errors and an overall breakdown in revenue cycle efficiency.
How to Fix It:
- Standardize Communication Protocols: Implement consistent communication processes across all team members in the practice.
- Use Shared Digital Tools: EHR and practice management systems are a great way to ensure all necessary documentation is accurate and accessible.
- Schedule Regular Cross-departmental Meetings: Training and information sharing sessions can help improve workflow coordination and prevent revenue loss due to miscommunication.
At a high level, staying on top of the more technical side of your billing workflow often comes down to resources and staff experience. A lot of these filing details can fall through the cracks when dealing with staff turnover and trying to keep up in a busy practice.
If you’re experiencing these struggles in your practice, it could be a sign to consider outsourcing some of your billing needs to a third party. This will free up your limited staff to focus on patients in the office and other revenue-generating activities for the practice. And ODs will be able to focus on more medical care instead of defaulting to routine care due to lack of time.
Keep an eye out for part three of this series where we will take a look at the financial and patient challenges that impact your reimbursement revenue.
Jerry Godwin is the President of OMS, a trusted partner dedicated to improving the patient care cycle by streamlining clinical and administrative workflows. With a focus on revenue cycle management, OMS helps practices operate more efficiently and profitably. Contact Jerry at: jgodwin@optmedsol.com
