Coding and Billing

Rejected Claims: Understand Why It Happened and Ensure Future Payments

By Eric Botts, OD

When claims are rejected, take steps to understand the reason for the denial and then ensure a similar denial doesn’t happen in the future.

If your office deals with rejected insurance claims then continue reading because you are not alone. Submitting medical claims is a constant in any optometric practice that provides medical eyecare in addition to routine eye exams. If you are investing in the latest technology, you have to pay for it. “Helping your patients utilize their insurance benefits is your responsibility because you are the medical expert” is a truthful statement, however, the number of doctors who are experts at medical billing is a small minority. Every rejected claim is a reminder of our mortality as insurance experts and further emphasizes the disadvantages most of us have in the world of medical claims.

The costs you incur as a result of rejected claims and the resubmission process add up quickly. Nothing is more frustrating than performing the highest standard of optometric care, making the correct diagnosis and recommending the appropriate treatment  plan followed by no financial reimbursement because your insurance claim is denied.

Part of the learning curve in becoming an insurance expert involves claim rejection; however you can minimize the financial pain by first preparing your office to successfully submit every claim correctly the first time. Each time you resubmit a claim costs your staff time and wages that you cannot recoup. If you follow these easy steps you can save time and guarantee full reimbursement for the services you provide.

1.    Verify that the group and individual NPI numbers you submit on your claims are correct and the same as the numbers Medicare has on file for you and your practice. Also verify they are associated with the correct PTAN # for each provider.

2.    Understand what diagnosis codes are billable for the different procedures you perform.

3.    Modifiers! Modifiers! Modifiers!  You have to understand when and how to use them for unilateral and bilateral procedures.

4.    When preparing the claim, accuracy is essential, so be sure the patient’s name, date of birth and ID# on the claim matches information on the insurance card.

If you are incorporated or have multiple doctors in a group practice then you are required to have both an individual NPI# and a group NPI# for the practice. Both NPI numbers are required on every claim in their respective places if you hope for your claim to be processed.

How you submit your claims is an important step that you must consider carefully before you begin the claim submission process. Before you decide how to submit claims, evaluate your practice’s strengths and weaknesses.

Assess If You Have the Resources to Handle Billing Yourself

If your practice is new then time may be available to submit your own claims. A busy, established practice may have experienced billing specialists that can efficiently submit claims for your office.  It is important that you give equal consideration to your weaknesses. You may be a novice when it comes to understanding the complexities of medical billing and not comfortable training your staff to accurately submit claims and receive full reimbursement for your services. If you practice in a corporate setting in a one-door state you may not have staff available to submit your claims. The biggest and most costly mistake you can make is to have claims denied repeatedly resulting in both lost revenue and wasted staff payroll and time. With all the choices available to help you with the insurance claim process there is no excuse for leaving exam revenue on the table because your claims are rejected or you are not billing appropriately and receiving less than the full reimbursement for your services. Any of the following are excellent options for you to consider.

1.  Hire and train a billing specialist for your practice. This requires that you and your staff must invest time in attending seminars, webinars and other education opportunities offered to keep up with the changing policies that are incorporated by the insurance industry. Health reform is a major topic these days and change is inevitable, therefore, you have to stay up-to-date.

2.   Outsource your medical billing to a medical billing company that understands optometry. The multitude of medical sub-specialties makes it impossible for billing specialists to be experts on every aspect of all the different health care providers. Optometry has its own unique procedure and diagnosis codes that your billing specialist needs to be familiar with.

3.   Invest in EHR software that will enable you to submit claims directly to a clearinghouse. You will still be responsible for submitting claims to secondary insurance and billing patients for any balance due.

4.    If you invest in EHR you may still use a billing service to submit the claims, submit the secondary claims and bill the patient for any balance due. A doctor utilizing EHR software and a billing service will require little-to-no billing expertise and have minimal responsibilities in the billing process beyond performing and documenting the exam. This option requires the doctor to document the exam; select the procedure and diagnosis codes and the billing service will do the rest. With some EHR software the billing service will directly access the claims from the practice software so the doctor’s responsibility ends once the exam is completed.

More and more offices are looking to outsource their medical billing needs as an efficient, cost-effective claim submission process for their practice. Medical billing for a full-scope optometric office utilizing various procedure codes for post-op cataract procedures, punctal plug insertion, foreign body removal and lash epilation becomes more complex and requires a billing specialist experienced in processing these claims. Consider the cost involved in training and retaining a billing specialist. Turnover is a serious problem since it may take six to 12 months to adequately train a new billing person to be an efficient claims specialist. It also requires that the doctor be experienced in the billing process and able to train the aspiring billing specialist or have access to an outside resource to train the assistant. Either way you also need to consider the cost of wages, vacation and benefits for the employee and realize that unless you are a busy multi-doctor practice you will not require the billing specialist to be fulltime. Therefore, if the assistant you want to hire requires a full-time position you will need to supplement their position with additional responsibilities. A well-trained billing specialist is sometimes difficult to retain because other medical offices are willing to hire them away because they are well trained and offer immediate billing expertise.

So, you see you have choices, and the only unacceptable decision is to remain on the sidelines of the full-scope optometric playing field while your colleagues are performing medical exams and receiving full reimbursement for their services. With the evolution of EHR and specialized optometric billing services there are no more excuses for not practicing optometry to the full extent that your license allows. Choose whether to do some or none of the insurance claim submission process and then get started. EHR will be an essential component as will highly-trained billing specialists either directly employed by you or contracted as part of a billing service specializing in optometric insurance billing. What are you waiting for? Now is the time to start practicing optometry smarter, not harder.

Related ROB Articles

Don’t Give Up: How to Retrieve Payment for Denied Claims

Cataract Co-Management: Do You Know How to Code for It?

Treating Ocular Trauma: Do You Know How to Code for It?

Eric Botts, OD, is founder and president of OBC Billing Specialists, and president of InnovativeEyes, in Macomb, Ill. To contact him:

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