Maximizing Reimbursement: Navigating The Complex World Of Optometry Insurance Billing

Billing optometry services to insurance companies can be a complex and challenging process, but it is crucial for the financial health of a practice. Optometrists need to understand the differences between vision and medical insurance plans and when to bill each type. While vision plans typically cover routine eye examinations and refractive care, medical insurance covers a broader range of eye care services, including medical diagnoses and treatments. Optometrists must also be aware of common billing mistakes, such as mixing up routine and medical exams, incorrect use of modifiers, and submitting claims before being fully credentialed. Understanding billing and coding procedures is essential to optimize reimbursement and avoid audits or fraud charges. Involving the patient in the decision-making process and considering their preferences and coverage is also important. By following best practices and staying up-to-date with coding guidelines, optometrists can effectively navigate the complexities of insurance billing and maximize reimbursement for their services.

Understand the difference between vision and medical insurance plans

Vision insurance and medical insurance are two different types of insurance plans, and it is important to understand the differences between them. Here is a detailed overview:

Vision Insurance:

Vision insurance is typically designed to cover routine eye care services. This includes periodic eye examinations, such as determining a patient's prescription for glasses or contact lenses. Vision insurance often offers benefits like allowances for glasses and contact lenses, including fittings and follow-ups. Some plans may also provide discounts on corrective eye surgery like LASIK. Vision insurance is usually supplemental to your regular health insurance and is often provided as an additional benefit by employers. It is important to note that vision insurance typically covers routine eye care and may not cover medical eye problems or emergencies. The frequency of coverage varies among plans, with some offering coverage once a year, while others may permit coverage multiple times a year as medically necessary.

Medical Insurance:

Medical insurance, on the other hand, is designed to cover medical eye care services. This includes the evaluation and management of eye emergencies, diseases, and other medical issues related to ocular health. Medical insurance often covers, or contributes towards, diagnostic tests such as digital imaging and visual field evaluations. It is important to note that medical insurance generally does not cover routine eye examinations or refractive services. Medical insurance typically has deductibles and co-pays associated with the coverage. In the case of physical trauma to the eye or vision impairment caused by another health issue, medical insurance is the appropriate coverage.

When to Bill Each Type of Insurance:

When billing patients with both vision and medical insurance, it is crucial to make the right choice to avoid fraud charges. The general rule is to bill based on the patient's chief complaint and diagnosis. If the patient has a specific complaint that can be attributed to a non-refractive diagnosis, it is considered a medical visit and should be billed to medical insurance. However, if the patient has no specific complaint and only comes in for a routine eye exam, it is typically billed to the patient's vision insurance. In cases where additional tests or diagnostics are required, billing both types of insurance may be appropriate, but it is crucial to never bill both simultaneously for the same service.

Know when to bill one or both insurance plans

Billing optometry services can be challenging, especially when patients have both medical and vision insurance plans. It is important to know when to bill one or both insurance plans to ensure accurate and efficient billing practices. Here are some guidelines to help you make this decision:

Firstly, it is crucial to involve the patient in the decision-making process. This means verbally informing the patient of your intentions and ensuring they understand and agree with the billing plan. Simply having a patient sign a document is not sufficient and may not be ethical or legal in some states. By discussing the billing plan with the patient, you demonstrate that you care about their health and financial well-being.

When deciding which insurance plan to bill, consider the patient's chief complaint and history of present illness. If the patient has a specific complaint, such as blurred vision due to cataracts, bill the patient's medical insurance with the appropriate eye exam code (92002-92014) and link it to the appropriate diagnosis code. In this case, you would use the cataract code (366.xx) and report 368.8 (Other specified visual disturbances [blurred vision NOS]) as the secondary diagnosis. If no underlying condition is found, report 368.8 as the primary diagnosis.

If the patient has no specific complaint and comes in for a routine eye exam, bill the patient's vision insurance with the appropriate E/M code (99201-99215) and link it to the ICD-9 code V72.0 (Special investigations and examinations; examination of eyes and vision). If a medical problem is diagnosed during this routine exam, report it as a secondary diagnosis. For example, if bilateral nuclear sclerotic cataracts are discovered, report 366.16 (Senile cataract; nuclear sclerosis) as the secondary diagnosis.

In some cases, you may be able to bill both the medical and visual insurance plans. If additional diagnostics or tests are performed during the routine screening, you can bill the initial visit to the patient's vision plan and bill any additional tests as medical. However, it is important to note that billing both companies for the initial exam is considered fraud. Always be transparent and honest in your billing practices to maintain ethical standards and avoid audits or fraud charges.

Additionally, it is important to understand the differences between "vision" and "medical" eye problems and convey this to the patients. Patients should know that their vision plan typically covers basic eye exams and glasses, while their medical insurance may be necessary for follow-up visits or medically necessary treatments, such as glaucoma management. By providing clear information and involving patients in the billing process, you can make informed decisions about billing one or both insurance plans.

Learn how to submit your claims

Submitting claims is a crucial step in the billing process, and it's important to do it accurately and promptly to ensure reimbursement from the payer. Here are the key steps to follow:

• Careful documentation: Optometry billing requires that you document all treatments, procedures, exams, and equipment used. This includes even simple vision exams. Accurate and detailed charting is critical, so be sure to record all relevant information in the patient's medical record.
• Use correct codes: When submitting a claim, you must use the appropriate CPT code, ICD-10 code, E/M code, HCPCS "S" code, or ophthalmic visit code, depending on the care provided. These codes are used to describe the services rendered and are necessary for reimbursement.
• Timely submission: Submit your claims within the required timeframe specified by the insurance carrier. Some plans may require claims to be submitted within 60 days, while others allow up to 12 months. Check with the insurance company to confirm their specific requirements.
• Follow up on denied claims: If a claim is denied, don't delay in addressing the issue. Determine the reason for the denial and make any necessary corrections. Resubmit the claim as soon as possible to increase the chances of a successful reimbursement.
• Hire a professional biller: Consider hiring a professional medical biller to handle your claims. They can ensure that your claims are submitted accurately and on time, improving your chances of reimbursement.
• Use electronic health records (EHR) and clearinghouse services: Utilizing EHR and clearinghouse services can make the claims submission process more efficient and help catch any errors before submission. Clearinghouse services can also provide trackable claim reports.
• Wait for approval: After submitting your claims, you will need to wait for approval or denial. Payment will only be released upon approval, so stay on top of the status of your claims.

By following these steps and staying organized, you can streamline the claims submission process and improve your practice's cash flow. Remember that accurate and timely claims submission is essential for maintaining a successful optometry practice.

Understand billing and coding for medical optometry

Understanding billing and coding for medical optometry is essential for running a successful optometry practice. Here are some key points to help you navigate this complex process:

Selecting Insurance Panels and Credentials

The first step is to choose the insurance company providers you want to offer at your practice. Different vision plans will impact reimbursements, new patient growth, and patient retention rates. Research the popular insurance providers in your state and consider the recipient pools to reach the most potential patients. For example, Medicare, with nearly 60 million recipients, is a widely accepted insurance provider that credentials all doctors who apply. Other commercial carriers like BCBS, CIGNA, and AETNA have better-paying plans but may be more challenging to credential for.

Setting Treatment Charges

When working with insurance panels, it's important to understand the allowable fees and out-of-pocket expenses for patients. For Medicare, review the Medicare allowables in your state to determine appropriate charges for various optometry services. This will help you set competitive and fair prices for your practice.

Submitting Claims and Reimbursements

Learning how to submit claims accurately and on time is crucial for receiving timely reimbursement from insurance carriers. This process often involves using Electronic Health Records (EHR), a clearinghouse to check for errors, and/or hiring a professional medical biller. Submitting claims correctly minimizes the chances of rejection and ensures a smooth revenue cycle for your practice.

Understanding Billing and Coding Procedures

Billing is typically handled by trained staff or outsourced to billing specialists. However, coding is the responsibility of the optometrist. It is essential to understand the different codes used in optometry, such as CPT codes, ICD-10 codes, E/M codes, and ophthalmic visit codes. Accurate coding ensures proper reimbursement and compliance with industry standards.

Optometry CPT Codes

Familiarize yourself with the CPT codes commonly used in optometry, such as 92004 (comprehensive medical examination for new patients), 92014 (comprehensive medical examination for established patients), 92002 (intermediate medical examination for new patients), and 92012 (intermediate medical examination for established patients). These codes cover medical examinations and evaluations, including the initiation or continuation of diagnostic treatment programs.

Modifiers and Additional Codes

Optometry billing also involves the use of modifiers to provide additional specificity to the codes. For example, RT and LT refer to the right or left eye. Other modifiers include -24 for unrelated evaluations during the postoperative period, -25 for separate and unrelated procedures on the same day, and -55 for co-managing a surgical procedure.

In addition to CPT codes, optometrists should also be familiar with procedure codes for specific treatments, such as bilateral procedures (e.g., 92250 Fundus Photos) and unilateral procedures (e.g., 65222 Corneal Foreign Body Removal). These codes have different billing structures, and it's important to understand when to apply them appropriately.

Tips for Improvement and Compliance

To improve your billing collections, ensure that the insurance payer has credentialed the provider and regularly follow up with insurance payers to stay in-network. Maintain accurate coding records for each patient visit and stay up to date with coding modifications, such as those provided by the CMS in 2019. Additionally, use modifiers correctly to avoid denials, rejections, and fines.

In conclusion, understanding billing and coding for medical optometry involves a deep knowledge of insurance panels, fee structures, claim submission processes, and coding standards. By following these guidelines and staying informed about industry updates, optometrists can effectively manage their practices and provide quality patient care.

Know the common optometry billing challenges to avoid

Billing for optometry services can be challenging, and optometrists often face obstacles in their daily practice. Here are some of the common challenges in optometry billing and how to address them:

Inefficient staff for data recording

With the increasing use of EMR and EHR, it is crucial for medical staff to efficiently record patient data in real time. Inaccurate or delayed data collection can disrupt the entire billing and coding process. Optometry practices should ensure they have a competent team for data entry, maintaining patient records, and resolving conflicts.

Medicare and Medicaid billing

With a significant number of patients covered by Medicare and Medicaid, optometry practices need to navigate the complexities of government carriers. While most private optometrists do not accept Medicare or Medicaid, they must still manage their revenue cycle effectively to maintain a healthy claim settlement ratio.

Bad debts and account receivables

Optometry clinics often face financial losses due to bad debts, which can account for about 30% of their annual revenue. These losses are often a result of irregular follow-up and customer dissatisfaction. To mitigate this challenge, optometry practices should implement regular follow-up procedures and ensure they meet data requirements to efficiently manage account receivables.

Medical billing service providers

Many optometrists choose to outsource their medical billing and coding to professional companies. While this can reduce errors and claim denials, it is important to select a competent and skilled billing partner. Optometrists should carefully evaluate the capabilities and expertise of the billing company to ensure they meet the specific needs of optometry medical billing.

HIPPA Compliance

Adhering to HIPAA rules and reforms for protecting patient health information (PHI) is crucial, especially when sharing data with insurance companies and carriers. Optometry practices must ensure their EMR and coding systems comply with HIPAA norms, adding an extra layer of complexity to their data management processes.

Claim settlement

Private insurance companies and government carriers often have specific compliance standards and pre-authorization requirements for optometry procedures. To maintain financial stability, optometry practices need to focus on accurate data collection, timely follow-ups, and efficient claim settlement processes. This includes managing accounts receivables and ensuring HIPAA-compliant data sharing.

Frequently asked questions