Many people often think ophthalmology billing is just about using the right codes, but most of the time, billers face more challenging situations. The kind that is very difficult to figure out, such as forgetting to add modifiers or mistakenly using the wrong code because it looks similar to the actual one.
Here’s the thing: when you’re staring at a growing A/R and watching clean claims rejected, you go down the rabbit hole to identify what is happening to your practice. Then, you start to notice small but significant patterns and mistakes in your billing process.
For example, a patient had cataract surgery, but no modifier was added to their claim. These small errors are often the culprit behind many claims' denial in ophthalmology practice.
Those denials lead to a lengthy process of appeals, and your 30-day A/R turns to 60, then 90. But there is a solution - implementing strategies that will ensure accurate ophthalmology billing and reduce administrative burden.
How Claim Denials Are Affecting Ophthalmology Practice
A claim denial is an occurrence where an insurance company refuses to pay a healthcare provider for a service that was billed. This often happens in ophthalmology billing when compared to other fields in medicine specialties because their services are specialized and require accurate coding, complete documentation, and constantly following regulations given by both the healthcare industry and payers.
Claim denials are one of the most significant and growing reasons many ophthalmology practices are losing millions of dollars. According to a 2024 survey of hospitals, health systems, and post-acute care providers conducted by Premier Inc., about 15% of all claims submitted to insurance companies are first denied. This not only affects revenue but every part of the practice's finances and increases staff burden.
Appealing a denied claim takes so much time, creating more administrative work for all your billing team who are already exhausted. Plus, the cost of gathering relevant documents and resubmitting the claim is also very high.
This not only reduces the practice's cash flow but also makes it difficult to cover everyday expenses such as staff payment, rent, and medical supplies. The delay in getting reimbursed can make the practice's accounts receivable days longer, further affecting your budget.
When ophthalmologists constantly experience these issues, it is a reflection of a broader problem in their revenue cycle. So, it is time to stop focusing on just submitting claims and improve your billing process to prevent denials from happening.
The Causes of Claim Denials in Ophthalmology Billing
Ophthalmology billing is not a very simple and straightforward process when compared to many medical fields. This is because they need to handle complex vision coverage, which is different from one insurance company to another.
It doesn't end there; ophthalmologists also perform many diagnostics and testing that require strict documentation and prior authorization. Without the right systems and knowledge, ophthalmologists can omit some of these necessities, leading to claim rejection.
Let's discuss some of the most common billing errors that contribute to denied claims in ophthalmology:
Improper Use of Modifiers
Modifiers are universal codes that are added to procedure codes in medical billing to provide additional information about the service provided without changing the actual meaning of the code.
In ophthalmology billing, many modifiers are used and can be
misapplied or omitted due to human error. Insurance companies are known for strictly reviewing these modifiers closely, and incorrect use will instantly lead to claim denials.
Therefore, it is important for providers to use modifiers accurately if they want to ensure consistent cash flow. They can also outsource their billing process to ophthalmology billing services to ensure accurate usage of modifiers.
Incorrect Code Usage
Matching the right codes to corresponding procedures is a must in ophthalmology billing and one of the most common sources of error. When the diagnosis does not clearly explain why the procedure was needed, the claim is likely to be denied.
For example, if a provider submit a claim for visual field test is billed without any supporting diagnosis of glaucoma, optic nerve damage, or neurologic condition, the insurance company may decide that the service was not medically necessary, even if the test was clinically indicated.
Failure to Document Medical Necessity
Before an ophthalmologist can be paid for the services they provide for their patients, they must provide complete documentation and ensure the treatment is considered necessary medically. They must also explain how the service is clinically important with proof when submitting their claim to the insurance company to avoid denials. Unfortunately, many providers struggle to keep up with these policies, leading to constant claim rejection and, in some cases, loss of opportunity to receive reimbursement.
Missing Prior Authorizations
Many expensive ophthalmologic treatments, such as intravitreal injections or advanced imaging, often require prior authorization from the patient's insurance company. When this process is omitted, no matter the reason, it will automatically lead to claim denial. While ophthalmologists can appeal the claim, most of the time, it doesn’t always succeed, which significantly affects their cash flow and revenue over time.
How To Prevent Claim Denial and Longer Account Receivable Days in Ophthalmology Billing
Complete Patient Documentation
Accurate and complete patient documentation is one of the most important steps to take for effective billing. Any mistake, no matter how small, during this process determines if the provider is reimbursed or not.
In ophthalmology, where expensive services often require proof of medical necessity, incomplete documentation will cause confusion and denial. Therefore, patient information and treatment journey must be documented correctly with detailed notes that include the diagnosis, the reason for each test or procedure, and the results that support the treatment plan.
Timely Claim Submission
When claims are not submitted within the time frame recommended by the insurance company, it has a higher risk of not being accepted. Therefore, ophthalmologists are advised to always send their claims within a day or two after every service,
Once submitted, the claim should be tracked to confirm whether they are accepted or rejected, and appeal should be initiated immediately if the latter happens. This strategy ensures a seamless billing process while identifying and addressing any mistakes quickly.
Use The Right Code
Ophthalmology billing requires specific coding that explains in detail the services offered to patients, in addition to test results and clinical notes. The right modifiers should also be applied to avoid confusion during claim processing.
By working with coders who have many years of experience and specialize in ophthalmology billing, providers are able to reduce their denials. Regular staff training to educate them about the recent coding updates and insurance policies will also ensure the submission of error-free claims.
Introduce Electronic Billing Option
Introducing electronic patient billing through your EHR patient portal or website is a smart strategy to also reduce your Accounts Receivable Days. With this process, providers make it easier for their patients to
pay their bills no matter where they are. It also reduces the time your administrative staff spends calling patients and manually collecting payments.
Consistent Follow-Up
While preventing denials is essential, reducing your practice A/R days cannot be abandoned. Reviewing the status of your claim weekly or within a few days allows you to make changes and appeal at the right time. Waiting for a month or two before checking its status is far too late and can affect your cash flow.
Outsource Ophthalmology Billing to Unify Healthcare Services
Unify Healthcare Services offers ophthalmology billing services for providers who want to receive timely reimbursement without going through the stress of the billing process.
We help maximize ophthalmology revenue through expert billers and coders with decades of experience in ophthalmology. Our Accounts Receivable management services reduce your A/R days and monitors every claim for prompt response.
