Coding and Billing

Why Your Coding Is Currently Coming Under Heightened Scrutiny & How to Protect Your Practice

By Mark Wright, OD, FCOVD,
and Carole Burns, OD, FCOVD

Dec. 7, 2022

Some third-party payers are increasing scrutiny of claim submissions. Here is how to ensure that your coding meets the new requirements, so your reimbursements and practice are protected.

It’s been reported to us that if certain third-party medical insurance providers believe that an optometrist is billing codes at a higher level than other providers in an area, they may adjust your reimbursement to a lower level without notifying you of the change.

To give a specific example, if, in their judgement, they believe that you have billed more 99214’s than other practices around you, then they may reimburse you at the 99213 level. It will still read 99214 on the EOB (Explanation of Benefits) and there will be no information sent to you stating that there has been a reduction in your reimbursement. The only way that you would know is if you are tracking the reimbursement rates.

There often is a hint given by the third parties about six months before the new reimbursement rates begin. Once the third parties determine you are billing a higher number of the specific codes than other practices in your area, you are sent a letter from the third parties identifying your billing pattern as different from other practices in your area. This letter does not contain information that your reimbursement is going to be affected.

This is the kind of letter that could be easily overlooked because it could be rationalized that you see sicker patients than other practices, and you know that you are carefully following coding rules, so logically, higher-level codes are being used appropriately.

This problem was brought before the Ohio Department of Insurance, and they said they are powerless to intervene to stop the actions of these third parties described above in this article.

What is the best action plan moving forward?

1)     Keep all correspondence from all third parties.

2)     Code appropriately realizing that under-coding is just as bad as over-coding.

3)     To see if this is happening to you, keep track of all reimbursements from each third party for which you are a provider. (This also helps you do an annual review of reimbursement rates as well as finding the problems described in this article.)

4)     Keep the third-party committees of your state and national optometric associations and your practice attorney aware of any problems like this that you discover.

5)     Submit a challenge to the third party at the supervisor level keeping track of all correspondence.

This situation seems completely unfair. You’ve done nothing wrong. If fact, you are trying your best to follow the rules exactly. The problem is currently being worked on and is not yet resolved. We’ll keep you in the loop.

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