6 Eye Care Billing Rejections You Can Overcome

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Are you noticing more eye care billing 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. To stay in business, you need to see a consistent, positive cash flow. You can’t achieve this if your claims keep getting rejected.  

Medical billing rejections and denials are often used interchangeably—however, there is a distinct difference. A rejected medical claim fails to meet specific formatting, billing criteria, and 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.

The good news is you can re-submit the rejected claim once you fix the errors. Don’t wait too long to re-submit the claim—some payers have short timely filing periods, as little as 30 or 60 days from the date of service in some cases. You cannot hold beneficiaries liable for a rejected claim since it was never billed.

Let’s examine six common eye care billing rejections you’ll likely face as an optometrist or ophthalmologist, and how a billing solution like Fast Pay Health can help you overcome them.

"We've been in business since 2007 and never received any payments from Medicare until Fast Pay Health stepped in to help us."

Shari Tullo, Princeton Optometry

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.

According to the Medical Group Management Association (MGMA), the average cost of reworking a rejected or denied claim is $25. Advancing the Business of Healthcare (AAPC) provides an online denied claims calculator to show what those reworks are costing you using the $25 MGMA average cost. 

If you take the 46 rejected claims the optometry practice received last month multiplied by $25 each, this equals $1,150 the practice spent to fix errors and re-submit the claims.

Costs incurred for re-submitting a claim adds 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.

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.

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Eye Care Billing Rejection #1: Mission 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, SSN-based Health Insurance Claim Number, or the new Medicare Beneficiary Identifier (MBI), this will trigger a rejection or denial.

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

A recent Black Book Survey reports an average of 33% of all denied claims at surveyed healthcare organizations were the result of inaccurate patient identification or patient health data. These inaccuracies are costing the U.S. healthcare system over $6 billion annually.

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

Check for New Medicare ID Cards

Starting in April 2018, CMS began mailing new Medicare cards to people with Medicare, based on a geographic location mailing strategy.

Medicare is removing the Social Security Number (SSN) from ID cards and is implementing an 11-character alphanumeric Medicare Beneficiary Identifier (MBI). MBI will replace the existing SSN-based Health Insurance Claim Number (HICN) by April 2019.

CMS will accept the SSN-based HICN during the transition period, April 1, 2018 through December 31, 2019. Starting January 1, 2020, providers must submit claims using the new MBI.

 Graphic Source: Medicare.gov

Graphic Source: Medicare.gov

MBI Tips

  • Replace the patient's SSN with the new MBI in the "Insured ID" field in your practice management software patient record, so the new ID will transfer to the e-claim and paper HCFA.
  • Check all Medicare patients' cards and verify that the patient address and name are correct. If the address you have on file is different than the Medicare address you get on electronic eligibility transactions, ask your patients to contact Social Security and update their Medicare records.

Eye Care Billing Rejection #2: Same Day or Duplicate

When you get the rejection message “Same Day or Duplicate Claim,” that means 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 didn’t receive reimbursement within 30 days. Before you refile 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 simply 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 re-submitting claims and issues related to rejected or denied claims.

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.

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 verifying co-pays for exam and materials for vision insurance plans.

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

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

Make sure you include the provider’s correct National Provider Identifier (NPI) and Taxpayer Identification Number (TIN) when submitting a claim. 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 provider has been credentialed by the insurance payer before submitting the claim. Some insurance payers may require providers to credential (get on insurance panels/board) with specific plans individually.

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.

Full-Service Eye Care Billing Solutions

While every 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.

Better ophthalmology and optometry billing is just a form submission away. Fast Pay Health is ready to help you focus more time and energy on your patients with complete revenue cycle management. The best part? Fast Pay Health works with any ophthalmology and optometry practice management software.

Complete the GET A FREE PRACTICE ANALYSIS! form on this web page and we’ll schedule a time that works for you. We work with each of our offices to provide a solid, customized revenue cycle management solution.

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