Claim denial management strategies for optometry and ophthalmology practices are critical to quickly identifying, resolving, recovering from, and preventing denied claims.

The longer you wait to resubmit or appeal denied claims, the higher the odds are you won’t recover the maximum amount from the insurance payer.

Industry stats reveal that 85% of denials are preventable, and 65% are never reworked or appealed due to a lack of time or knowledge about resolving the claim.

How can you keep the denial rate below 5% and boost unhealthy cash flow? The key takeaway is don’t delay. Resolve the issue(s) immediately and review, correct, and resubmit denials within the week.

Below are common reasons for claim denials and solutions to help improve your cash flow.

1. A duplicate claim was submitted for the same service or procedure.

Before re-filing an unpaid claim, always check with the insurance payer since they may be processing it. Find out why the claim wasn’t paid or if the clearinghouse rejected it.

2. The patient isn’t eligible for services because the health plan coverage ended.

Always check the patient’s insurance card when they check-in and confirm coverage. Copy both sides of the card to ensure you have the correct claims filing address and important information.

3. The physician isn’t an in-network provider.

Make sure the insurance payer has approved the provider. Submit and track provider credentialing applications based on insurance plan requirements. Follow up with insurance payers regularly to ensure the providers are enrolled in-network when enrollment opens.

4. Missing or invalid patient demographic and insurance information.

Always confirm the spelling of the patient’s name, date of birth, responsible party, and vision and medical plan numbers. Even one required field or transposed number/letter will trigger a denial.

5. The benefit exceeds the allowed number of visits or services.

Confirm the patient’s eligibility with the insurance payer. Many insurance payers only cover a certain number of visits or services within a calendar year.

6. The chief complaint was missing.

When you document the chief complaint, provide a concise description of the problem or laboratory test. This will help you if you are ever audited. A missing chief complaint can result in a claim denial based on incorrect levels of care.

7. The claim requires a prior authorization number.

Verifying a patient’s insurance benefits is a critical first step in the RCM process. Whenever possible, authorizations from the insurance payer should be obtained before the patient visits your office. Before submitting any claim, double-check that the prior authorization number is included on the claim.

8. The referring physician and referral information is missing.

Confirm if you need a referral (written order) from the patient’s primary care provider and that the referral number is correct on the claim. This will support the continuity of care and provide a clear patient treatment record.

9. The claim is missing a code or modifier, or the modifier is invalid.

Modifiers are added to the HCPCS or CPT® codes to identify why a doctor provided a specific service or procedure. Not all modifiers can be used with all HCPCS or CPT codes.

Payers will reject your claim if even one of the procedure codes is inconsistent with the modifier used or a required modifier is missing for the date of service being billed. For example:

Modifier 25 is one of the most commonly misused modifiers. Use modifier 25 when you perform a procedure—and a significantly unrelated and separately identifiable evaluation and management (E/M) service—during the same session or on the same day. Do not use modifier 25 to an E/M service that results in a decision to perform surgery—use modifier 57 instead.
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 code and add modifier 59 to the second procedure.

For more billing tips, check out our blog, How (and How Not) to Use Common Medical Billing Modifiers, for red flags to look out for when billing with common modifiers.

10. Services should have been billed separately and not bundled.

Some services can’t be filed separately and may require bundling, such as laboratory profiles with multiple tests or an all-encompassing rate that covers the minor procedure and the pre- and post-procedure visits.

11. The place-of-service (POS) doesn’t match the procedure performed.

Correct the place of service code or CPT® code and resubmit the claim. Ensure the POS matches the setting where the patient received the service (face-to-face services) or the setting where the technical portion of the services was delivered (non-face-to-face services, such as the interpretation of diagnostic test results).

12. Service isn’t covered under the plan’s benefits or isn’t medically necessary.

Check your Local Coverage Determinations (LCD) policies on the insurance payer’s website for a list of covered diagnoses.

13. Post-operative care dates are missing from the claim.

Confirm the post-operative dates and update the claim form with the missing dates. These dates are required to identify the period of post-operative care you provided to the patient. The dates also verify that the care falls within the global surgical package.

In addition, depending on the insurance plan policies, you may need to file a new claim form or amend the original. Check with your insurance payer to prevent further delays or denials.

14. The National Drug Code (NDC) identifier is missing.

The NCD is a unique medication identifier that provides essential details (labeler, product, and package size). It’s important to include the NDC ID on medical claims. The ID ensures accurate billing and reimbursement by distinguishing between drugs that may share the same Healthcare Common Procedure Coding System (HCPCS) or Current Procedural Terminology (CPT®) codes.

15. The filing deadline has passed.

Pay close attention to the permitted time frame. Each insurance carrier has its own guidelines. Sometimes, you only have 30–90 days from the service date to submit a claim. Otherwise, it will be denied, and you can’t bill the patient or appeal to the insurance company.

Pro Tip: AAPC provides a free denied claims calculator to show how much each claim denial can cost your practice (revenue loss and reworks).

Invest in a solid claims optometry and ophthalmology denial management solution

The best billing and revenue cycle management solutions pay close attention to credentialing, eligibility verification, charge entry, coding, and claim submission requirements before you push the “Send” button.

Fast Pay Health optometry and ophthalmology billing specialists ensure your claims are scrubbed clean and error-free before we submit them. This proactive process decreases claim denials and delivers consistent and positive cash flow for your practice.

Request a free practice analysis today and start enjoying the advantages of cleaner claims that focus on improving the financial health of your eye care practice.

CPT® is a registered trademark of the American Medical Association®.

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15 Claim Denial Management Solutions to Improve Cash Flow