6 Eye Care Claim Rejections You Can Overcome

Are you noticing more eye care claim rejections appearing in your inbox? Is your claim rejection percentage rate increasing? Reducing your accounts receivable (AR) is the lifeline for every ophthalmology and optometry practice.

Every eye care practice needs to see a consistent, positive cash flow to stay in business. If your vision plan and insurance claims keep getting rejected, you can't achieve this.

Let’s examine typical eye care billing rejections you’ll likely face and how a complete insurance billing and collection service like Fast Pay Health can help you overcome them.

Why Are Insurance Claim Rejections and Denials Different?

Insurance claim rejections and denials are often used interchangeably. However, there is a distinct difference.

A denied claim is a claim that has made it through the adjudication system—the insurance company or third-party payer received and processed the claim.

A rejected medical claim fails to meet specific formatting, billing criteria, and data requirements. A rejected claim contains one or more errors and fails to meet specific formatting requirements, billing and coding standards, and patient data requirements.

Because a rejected claim has never been processed by a clearinghouse, insurance payer, or the Centers for Medicare & Medicaid Services (CMS), the claim is not considered received and it did not make it through the adjudication system.

While you cannot hold beneficiaries liable for a rejected claim since it was never billed, the good news is that you can resubmit the rejected claim once you fix the errors.

Related: Common Medical Billing and Insurance Terms You Should Know
Related: Rules to Follow for Advance Beneficiary Notice of Noncoverage

Typical Eye Care Billing Rejection Costs

Recently Fast Pay Health spoke with one of our clearinghouse partners about an optometry office who had a 40% claim rejection rate (46 claims) last month.

Since the average cost of reworking a rejected or denied claim is $25, if you take the 46 rejected claims the optometry practice received and multiply them by $25 each, this equals $1,150 the office spent to fix errors and resubmit the claims.

Costs incurred for re-submitting a claim add hours to your staff time and wages that you can’t get back. A worst-case scenario is if you don’t re-submit the claim to the insurance payer within the permitted time frame, it will probably get rejected again.

Don’t wait too long to re-submit the insurance claim—some payers have short timely claim submitting filing periods, as little as 30 or 60 days from the date of service in some cases.

To make it even more complicated, sometimes, you only have up to 90 days from the date of service to submit a claim. 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.

PRO TIP: If you want to speed up the billing process, choose a clearinghouse that integrates with your eye care EHR and practice management software so you can easily manage patient and insurance billing with built-in edit checks.

Eye Care Billing Rejection #1: Missing or Invalid Information

Always confirm pertinent demographic 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 or the Medicare Beneficiary Identifier (MBI), this will trigger rejection or denial.

A claim will be rejected even if one digit in an ID has been transposed. Pay close attention when entering the patient’s name, age, date of birth, gender, and address.

At Fast Pay Health, we track all claims we submit electronically through vision plans and clearinghouses and ensure that insurance payers accept the claims. If we notice a rejection, our team promptly fixes the errors to ensure timely accounts receivable.

Related: 10 Medicare and Medicare Advantage Medical Billing Dos and Dont’s

PRO TIP: Collect patient information with EHR digital patient intake forms before the patient arrives in your office. Once patients complete the form on their smartphone, tablet, laptop, or home computer, they click the submit button to send the data back to your practice for import into your practice management system with an automatic or manual import.

Eye Care Billing Rejection #2: Same Day or Duplicate

When you get the rejection message “Same Day or Duplicate Claim,” the claim was processed twice on the same day. For example, according to CMS, Medicare will not pay duplicate claims for the same service encounter. CMS will pay the first claim that is approved and deny subsequent claims for the same service as duplicates.

Did you submit the same claim twice? This often happens if you don’t receive reimbursement within 30 days. Before refiling a claim, always check with the insurance payer first since they may be processing the claim.

Eye Care Billing Rejection #3: Code or Modifier Missing or Invalid

Did you submit an incorrect procedure code or modifier on the claim or leave it blank? Payers will reject your claim even if one of the procedure codes is inconsistent with the modifier used, or a required modifier is missing for the date of service being billed.

It’s important to keep up with Local Coverage Determinations (LCD) for your area to ensure you are coding claims correctly. Follow existing procedures for correcting and resubmitting claims and issues related to rejected or denied claims.

“The Fast Pay Health billing team works so hard for our office. I used to worry about the billing ALL the time. Now, it’s the one thing I know is being done to a large extent!” ~Dr. Julie Honda (Kailua-Kona, HI)

Eye Care Billing Rejection #4: Patient Not Eligible

Verifying a patient’s insurance eligibility for the date of service and benefits is a critical first step in the optometric revenue cycle management process. If you ignore verifying insurance eligibility and benefits upfront, you risk unhealthy and serious revenue problems down the road. Focus on your accounts receivable and aging buckets now before they become unmanageable.

Verify that insurance data is correct by confirming the insurance plan policy effective and term dates. Obtain prior authorization for specific services, if needed. Verify the patient’s out-of-pocket costs, such as co-pays, co-insurance, and deductions, as well as verify co-pays for exams and materials for vision insurance plans.

At Fast Pay Health, we’re experts at verifying patient eligibility before submitting the claim to the clearinghouse or insurance company.

Related: Reduce Denied Claims with Proactive Insurance Eligibility Verification

Eye Care Billing Rejection #5: Missing or Invalid Billing Provider ID

When submitting a claim, ensure that you include the provider’s correct National Provider Identifier (NPI) and Taxpayer Identification Number (TIN). If the payer doesn’t have the correct provider IDs on file to validate the billing provider’s identity, they will reject the claim.

Eye Care Billing Rejection #6: Provider Not Credentialed by Payer

Always make sure the insurance payer has credentialed the provider before submitting the claim. Some insurance payers may require providers to individually credential (get on insurance panels/board) with specific plans.

If the provider isn’t properly credentialed or re-credentialed with the insurance company, the insurance payer will not reimburse the provider for services rendered.

Fast Pay Health simplifies the credentialing process by reviewing documentation to determine the participation status in the health plan, then submitting and tracking provider credentialing applications based on insurance plan requirements.

Related: Critical Steps for Efficient Provider Credentialing and Enrollment

Get Paid Faster with Complete Optometric Billing Services

While every eye care practice will experience claim rejections and denials, knowing how to prevent those rejections in the first place is the best cleaning solution to receive revenue quicker and bring your out-of-control accounts receivable back in control.

Better ophthalmology and optometry insurance billing is just a form submission away. Fast Pay Health works with any ophthalmology and optometry practice management software. We get paid when you get paid, and there are no setup fees and no monthly minimum.

Get started today with a free, no-obligation practice analysis.