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Major reasons for Denials in Optometry

March 18, 2016


Major reasons for Denials in Optometry

A key source of frustration and dwindling revenues for physicians and healthcare providers is the denial of claims. It is essential for practices to identify the reasons, nail them to avoid future non-payments, and determine approaches that can work towards improving the financial functioning of the practice.

Below mentioned are the reasons for denials in optometry:

  • Duplicate claims:
     A very common error is that claims submitted are the exact replica of some previously submitted claims. This happens because sometimes the reimbursement has not reached the healthcare provider within 30 days. It is important to first check with the insurance payer before re-filing the claim as the payments could be in process.
  • Non-covered service: :
    Especially in optometry, there are a number of omissions. Services such as eye exams only for the purpose of prescription, fitting/changing of contact lenses/glasses in case of no injury/disease etc. are not covered under Medicare. It is imperative to be aware of such billing rules before filing claims.
  • Medical Necessity:
    In Optometry, some payers deem various services a non-medical necessity which need no further treatment and hence do not reimburse. A better practice is to check the LCD (Local Coverage Determination) beforehand on the carriers' website for a list of covered diagnosis.
  • Secondary Payer:
    The patient could be having Medicare as the secondary payer due to the reasons such as: working/retirement/aged, liability and no-fault/auto liability, workers compensation, and/or veteran's affairs. For better co-ordination and compensation, check with the service provider department.
  • Diagnosis:
    Sometimes, a primary diagnosis for an illness/procedure performed could be treated as a secondary or a non-covered diagnosis and hence not covered under the insurance scheme. Check the insurance payer's LCD policy. Yet again, a diagnosis cannot be performed only because it is covered. As a strict policy, it needs to be proven, documented and justified in the medical record. Also, be vigilant of software that could present details of a covered diagnosis for a certain procedure which is essentially not covered.
  • Missing information:
    A missing/incomplete or invalid modifier mentioned against a procedure on the claim form could be a reason for denial. Moreover, remember to enter the exact PIN (Personal Identification Number) or the NPI (National Provider Identifier) number. As a billing professional, keeping oneself updated for this complex service is extremely important. For success, Optometry policies and guidelines must be followed to ensure greater profitability.

Category : Revenue Cycle Management