25 Oct Top Reasons Optometric Billing Claims Get Rejected or Denied
Researching rejected or denied optometric billing claims takes time and effort. Even one mistake could result in a claim being rejected or denied, leading to significant financial losses.
Filing optometric billing claims requires attention to accurate patient information, diagnosis and procedure codes, and evolving billing rules and insurance regulations. Billing errors can strain your relationship with patients or create conflicts.
Below, First Insight’s Fast Pay Health optometric billing and revenue cycle management (RCM) team shares the top reasons optometry and ophthalmology claims get rejected or denied and how you can troubleshoot claims.
Patient information is missing or invalid.
Verifying a patient’s insurance eligibility for the date of service and benefits is a critical first step. Always confirm pertinent information from the patient at check-in or during the data entry process for the claim.
Even if one required field is missing or invalid, such as an insurance plan ID, SSN-based Health Insurance Claim Number, or the Medicare Beneficiary Identifier (MBI), this will trigger a rejection.
A new or established patient is not clear.
Patients are considered new if doctors have not seen them with the same specialty and subspecialty within a group practice in the last three years. For solo providers, this is simple—if the patient hasn’t been seen in the last three years, they’re considered new. But for larger group practices, it can get tricky.
Keeping proper records can help avoid this type of rejection. Sometimes, an insurance payer may incorrectly reject a claim for a new patient exam. Most of the time, this can be cleared up with a phone call to the payer, though some cases may require an appeal with medical documentation.
The referring or ordering physician is not listed on the claim.
In most cases, the referring or ordering physician may be the same as the rendering physician. However, failure to include this information will result in a denial and delay payment. If a required physician is missing, Medicare will often split those codes from the rest of a claim to expedite payment.
For example, in optometry practices, this is often seen with pachymetry when billed concurrently with an exam. Medicare will split off the pachymetry to return a denial for missing the referring physician while separately processing and paying for the exam.
The insurance payer didn’t credential the provider.
Ensure the provider has been credentialed by insurance payers and the Council for Affordable Quality Healthcare (CAQH®) before submitting the claim. Some insurance payers may require providers to credential (get on insurance panels/boards) with specific plans individually.
Fast Pay Health simplifies the credentialing process by reviewing documentation to determine the participation status in the health plan and then submits and tracks provider credentialing applications based on insurance plan requirements.
The service isn’t medically necessary.
A service that was medically necessary last year may now be a non-medical necessity, which means it isn’t covered by the insurance payer. Check your Local Coverage Determinations (LCD) policies on the insurance payer’s website for a list of covered diagnoses.
Incorrect or missing NPI, TIN, Code, or Modifier.
When submitting a claim, check that you included the provider’s correct National Provider Identifier (NPI) and Taxpayer Identification Number (TIN). If the payer doesn’t have the correct provider IDs to validate the billing provider’s identity, they will reject the claim.
Did you submit the incorrect diagnosis code, procedure code, or modifier on the claim? Or did you leave it blank? Payers will reject your claim even if one of the procedure codes is inconsistent with the modifier you used or a required modifier is missing for the date of service being billed.
Be careful, as modifier 59 is one of the most used and often used incorrectly. Never attach modifier 59 to an E&M service. Depending on the local policy, if the tests are necessary due to two separately identifiable conditions, you may be able to link the appropriate diagnosis code to each CPT® and add modifier 59 to the second procedure.
The chief complaint was missing.
When documenting the chief complaint, concisely describe the problem or laboratory test. This will help you in case you are ever audited. A missing chief complaint can result in a claim denial based on incorrect levels of care.
Benefit exceeds the allowed number of visits or services
Many insurance payers only allow a certain number of visits or services covered within a calendar year. Some insurance payers may also limit the number of visits within a 60-day period.
For instance, some insurance payers only allow one eye exam per calendar year or every other year. Always confirm the patient’s eligibility benefits with the insurance payer.
Verifying a patient’s insurance eligibility and benefits is a critical first step before you submit an insurance claim to a clearinghouse or vision insurance plan payer. Insurance eligibility verification remains one of the top reasons for claim denials.
Services weren’t bundled correctly.
There are some services you can’t file separately and may require bundling. Examples include laboratory profiles with multiple tests or an all-encompassing rate covering the minor procedure and pre- and post-procedure visits.
A duplicate claim or service was submitted.
Did you submit the same claim twice? This often happens if you don’t receive reimbursement within 30 days. Before re-filing a claim, always check with the insurance payer since they may be processing it.
The filing deadline has passed.
If a claim is not submitted to the insurance payer within the permitted time frame, it will probably get rejected. Sometimes, you only have up to 90 days from the service date.
In addition, if a patient has secondary insurance, you can run into timely filing denials. Many payers require you to bill a secondary carrier within a specific period after you receive the primary payments.
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