Maximizing Optical Insurance Benefits: A Guide To Efficient Billing

Billing optical insurance is a complex process that requires careful consideration of various factors. It involves understanding the differences between routine and medical eye exams, selecting the appropriate insurance panels, and navigating the intricacies of coding and billing procedures. Optometrists need to be well-versed in these processes to ensure accurate reimbursement for their services and provide clear information to their patients. While medical billing can increase practice revenue and expand eye care services, it is essential to be aware of potential challenges, such as denied claims and audits from insurance companies. Ultimately, effective billing and coding practices are crucial for a smooth and profitable optometry practice.

Understanding medical billing and coding

Medical billing and coding are crucial processes within the healthcare revenue cycle. They ensure that healthcare providers are accurately reimbursed for the services they provide. While closely related, they perform distinct roles.

Medical Coding

Medical coding involves translating healthcare services into universal codes. These include diagnoses, procedures, medical equipment, and more. There are several types of codes used, including:

• ICD-10 (International Classification of Diseases, 10th Revision): These codes represent a patient's diagnosis and reason for the visit.
• CPT (Current Procedural Terminology): These codes represent the specific procedures and services performed by the healthcare provider.
• HCPCS (Healthcare Common Procedure Coding System): These codes are used mainly for billing Medicare and Medicaid and include a range of codes not covered by CPT.
• Modifiers: These are additional codes appended to CPT codes to provide more information, such as whether a procedure was bilateral.

Medical Billing

Medical billing involves creating and submitting claims to insurance companies to receive payment for services provided. The medical bill, or claim, includes the codes created during the medical coding process, the patient's insurance information, and other relevant data. The goal of medical billing is to accurately and promptly submit claims to secure revenue for healthcare providers. After a claim is submitted, the insurance company processes it and returns an approval or denial. If approved, the provider receives reimbursement. If denied, the claim may be corrected and resubmitted.

The medical billing and coding cycle can take anywhere from a few days to several months, depending on the complexity of services rendered and other factors. It typically starts with patient registration and ends when the provider receives full payment for all services.

Understanding the Difference

Medical coding and billing are two distinct but closely related functions in the healthcare industry. A medical coder focuses on assigning standardized codes to healthcare services, while a medical biller focuses on the submission and processing of claims for reimbursement based on those codes. Both functions are essential for accurate documentation, proper reimbursement, and financial management within healthcare organizations.

Selecting insurance panels and credentialing

Selecting the right insurance panels to be a provider for is extremely important for increasing your practice's profitability.

Selecting Insurance Panels

Before selecting the panels for your practice, do some research to find out who the largest employers in your community are, as well as the reimbursements on the different vision plans you may choose to participate in. Different states (and different carriers) have completely different credentialing rules, so there’s never a one-size-fits-all solution.

Medicare is a good option as it has nearly 60 million recipients today (and is likely to increase to 80 million by 2030). By volume alone, these patients can be found everywhere, making Medicare a must-have provider. Beyond that, Medicare also credentials all doctors that apply, whereas some carriers will close their panels or limit the number of optometrists they credential.

Medicaid can be a good option if your practice is not as busy. Medicaid beneficiaries are one of the fastest-growing insured populations in the country, but it’s important to keep in mind that Medicaid has lower reimbursement rates than Medicare in all states and can be significantly lower in some. Beyond the state-sponsored carriers, commercial carriers like BCBS, Cigna and Aetna are typically better-paying plans but, as mentioned, can be more difficult to credential for. Take the time to review your options carrier by carrier to best understand which options best fit your patient population.

Credentialing

To become a "provider" with an insurance company, you must be credentialed with that particular insurance. Most medical and vision insurances have their own credentialing processes and procedures. Optometry credentialing can be a long and arduous process, ripe with confusion and frustration.

The first step in becoming a provider for insurance companies like Medicare, Medicaid, Cigna, Aetna, and others is setting up your business or finding a place to practice. If setting up a business, you must decide if your business will be a sole proprietorship or a corporation. It is recommended that you consult a lawyer or accountant to ensure you make the right decision based on your situation.

The next step is to apply for and receive your state professional license. Once you have been notified that your license has been approved, be sure to print out a copy that can be sent with your credentialing applications.

When applying for your NPI number, make sure that you are using your legal name as listed on your Social Security Card. You will have to list your Social Security number on your NPI application. You will also have to have a practice location to link to on the NPI application.

You will then need to establish your Tax ID. After you have decided if you want to be a sole proprietor, an LLC, or a Corporation, you can apply for the tax ID using whatever name you choose for your legal business name, and the type of business you will register as.

You must then register for CAQH. Almost all insurances except Medicare and Medicaid require that you have CAQH and that it is up to date. It is a centralized resource that houses all of a provider's information in one place and it eliminates duplicate paperwork. To complete CAQH, a provider would need all of their education information, their work history, and a few references (this varies by state). Depending on the state, you may also need to submit a professional license, DEA certificate, Certificate of Insurance, and/or resume.

Finally, you must determine which vision insurance plans and medical panels to participate in. Talk with your peers for help. Go to local society meetings and find out what others in your area are credentialed for. Call the large employers in your area to see what they have available for their employee health insurances. Check out the websites of other doctors in your area to gather some insight and information on what insurances they are taking.

Learning how to submit claims

Firstly, it's worth noting that direct billing is an option for some providers. Direct billing means that the provider will bill your insurance company directly, so you don't have to deal with any paperwork, claims or phone calls. This is a quick and easy way to claim your insurance benefits and means you don't have to pay the full purchase amount upfront. However, not all providers offer direct billing, so you may need to submit a claim manually.

If you need to submit a claim manually, the process will vary depending on the insurance company. However, there are some general steps you can follow. Firstly, check your insurance benefits before you shop to know which products are eligible and what you're covered for. Then, log in to your insurance account and start the claims process. You'll need to enter your insurance information and upload a valid prescription. After that, you can complete your order and pay any remaining amount after your insurance has been applied. Make sure to submit your claim within the time limit—for example, Medicare claims must be filed no later than 12 months after the date the services were provided.

It's important to avoid common mistakes when submitting claims. For example, submitting an eye exam procedure code with a refractive diagnosis code will usually result in a claim denial. Additionally, be careful not to commit insurance fraud by bundling, or including certain procedures as part of another separate billable procedure. Finally, remember that vision insurance companies may not allow you to bill your patients' medical insurance, so review your vision plan contracts carefully.

Knowing proper optometry billing and coding procedures

Education and Training

It is crucial for optometrists to educate themselves on proper and ethical coding procedures. While much of this knowledge may not be covered during optometry school, it is the doctor's responsibility to become an expert in optometry billing and coding. Familiarize yourself with common eye exam CPT codes and when to use them. Resources such as ICD10data.com can assist in learning diagnosis codes, and coding booklets or consulting experts in the field can also provide valuable guidance.

Credentialing

Before you can begin billing insurance for your patients, you must select insurance panels and credential for them. Research the largest employers in your community and the reimbursements offered by different vision plans. Keep in mind that credentialing rules vary by state and carrier, so there is no one-size-fits-all solution. Medicare, with its large number of recipients, is a must-have provider, and they credential all doctors that apply. Medicaid is another good option, especially if your practice is not as busy, but keep in mind their lower reimbursement rates. Commercial carriers like BCBS, CIGNA, and AETNA typically offer better reimbursement rates but can be more challenging to credential for.

Understanding Routine vs. Medical Exams

Distinguishing between routine and medical exams is vital to ensure full reimbursement for your services. The primary diagnosis and chief complaint will often drive the exam type. If the primary diagnosis is medical and addresses the chief complaint, the exam will likely be billed as a medical exam. However, don't assume that blurry vision always indicates a refractive issue. Blurry vision can sometimes result from an underlying medical condition, requiring a medical ocular exam instead of a routine exam. The decision-making process also differs between medical and routine exams, with the former typically involving low or moderate complexity, while the latter requires little to no medical decision-making.

Coding Procedures

Coding should always be performed by the doctor, who is responsible for choosing the correct codes for each patient encounter. CPT codes 92004, 92014, 92002, and 92012 are commonly used in optometry and can be broken down into comprehensive and intermediate levels. CPT code 92004, for example, covers a comprehensive medical examination and evaluation for a new patient. In addition to CPT codes for office visits, familiarize yourself with procedure codes such as bilateral procedures (e.g., 92250 Fundus Photos) and unilateral procedures (e.g., 65222 Corneal Foreign Body Removal).

Common Mistakes to Avoid

Even experienced optometrists can make mistakes in billing and coding. Some of the most common errors include mixing up routine vs. medical exams, using modifiers incorrectly, and submitting claims before being fully credentialed. These mistakes can result in denied claims or audits, so it is crucial to understand the differences between exam types and the correct usage of modifiers. Additionally, ensure that you are fully credentialed before submitting claims and that you have established whether you are a sole proprietor or corporation.

In conclusion, proper optometry billing and coding procedures are essential for the financial health and smooth operation of your practice. By educating yourself and your staff, selecting the right insurance panels, understanding exam types, correctly using codes, and avoiding common mistakes, you can ensure timely and efficient reimbursement and provide a better experience for your patients.

Common mistakes in billing and coding

Billing and coding for optical insurance can be a complicated and burdensome process, but it is crucial to get it right to avoid serious ramifications for your optometry practice. Here are some common mistakes in billing and coding:

Inaccurate Determination of Routine vs. Medical Exams

It is important to distinguish between routine and medical exams to ensure proper reimbursement. Routine exams are typically more regular and require little medical decision-making, whereas medical exams refer to patients with a chief complaint that leads to a diagnosis or further examination. Misidentifying the type of exam can result in incomplete reimbursement for your services.

Incorrect Use of Modifiers

Modifiers are used to describe optical services more accurately, but incorrect usage can lead to denied claims. Modifiers like RT/LT for right and left eye/lid, and E1-E4 modifiers for right and left, as well as superior and inferior lids, must be used correctly. A simple typo can change the meaning of a claim and result in denial.

Improper Credentialing or Submitting Claims Before Credentialing

It is crucial to obtain adequate credentials from insurance panels before accepting their beneficiaries as patients and submitting claims. Submitting claims before being fully credentialed can result in denied claims. It is also important to decide if you will be a sole proprietor or corporation before beginning the credentialing process.

Over-Charging, Under-Billing, or Incorrect Coding

Over-charging on billing can lead to serious consequences, including charges of fraud and other criminal penalties. Under-billing can result in significant financial losses for your practice. Incorrect coding, such as using only eye codes (E&M codes) or submitting claims with incorrect codes, can also trigger financial audits, expensive fines, and even fraud charges.

Using "Unspecified" ICD-10 Diagnosis Codes

The ICD-10 coding system provides detailed information about a patient's medical issues. When ICD-10 was first introduced in the US, it was mandated that codes should be submitted with the highest level of specificity, and "unspecified" codes would not be accepted. Submitting unspecified codes may imply that the optometrist did not thoroughly examine the patient, potentially questioning the medical necessity of the exam.

Insufficient Documentation

Insufficient documentation is one of the main reasons for improper payments. This includes missing or inadequate records, certification/recertification errors, and missing or inadequate orders for special testing. Proper documentation ensures that the billed services were provided, are billed at the correct level, and are medically necessary.

Frequently asked questions