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Test Your Claim Filing and Optometry Billing Knowledge

Posted by Janelle Pauli on May 21, 2016 11:00:00 AM
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Managing insurance claims and the optometry billing cycle in your eyecare practice is a big part of keeping your practice's revenue stream on track. Which makes billing and claims a huge part of your practice's success. Your billing team needs to be on their A-game to keep things running smoothly in your practice.

Today, we generated three random questions to help determine your claim filing IQ.

Can You Answer These 3 Optometry Billing Questions?

Do you know the difference between rejections and denials?optometry billing quiz

When it comes to describing an insurance claim status, many people use the words rejection and denial interchangeably. But really, a rejected claim is quite different from a denied claim. Do you know what sets them apart?

  • Rejections - According to the CMS, claims that don't meet the basic format or data requirements are rejected. These claims never make it to the payer, and are never processed. These rejections need to be fixed and resubmitted. 
  • Denials - These claims are received by the payer, but don't result in a reimbursement. Denied claims can't be resubmitted since payment determination was already made. Instead, these claims are appealed based on payer-requested modifications or additional documentation. The reason for the denial will appear on your ERA or EOB.

Do you know how to avoid denials due to duplicate claims?

Duplicate claims are often the most common reason for denials in a practice. These claims are two or more submitted claims that include repeated info about patient demographics, provider, date of service, and billing codes. How do you handle these when they happen?

Duplicates happen more often when the biller finds an unpaid claim in the system and assumes that it hasn't been processed. In an attempt to fix the problem, they file it again without researching the original submission. There can be many reasons that explain why a claim is unpaid. Processed claims could have gone towards a deductible or have been denied. Filing the claim again creates a duplicate until you correct it.

Investigate why a claim isn't paid by checking out your EOB or ERA so you can take the proper steps to fix it. Once you know what information needs to change you can resubmit the claim electronically through a clearinghouse instead of calling the payer. Don't forget to refer to the claim you're trying to correct as well as the claim control number (CCN) or internal control number (ICN).

Do you know how to avoid a disjointed claim filing workflow?

If your practice is struggling with a disjointed claims workflow, it might be because you're managing too many different processes to support your workflow efficiently. A lot of practices think it's ok to use paper records at the beginning of their workflow as long as they have a clearinghouse manage their claims at the end of the workflow. But, using a combo of both paper records and electronic can expose you to inaccurate coding and claim denials.

In order to get your workflow on track, you should ditch things like paper charts, filing claims manually, and duplicate data entry situations. Using a fully integrated solution that includes an EHR, practice management system, and a clearinghouse is the best way to streamline your claims workflow.

Starting from the exam, an EHR can help by auto-populating codes according to diagnosis chosen. Some systems will even provide code verification alerts that let you know when services can or can't be performed on the same day. And, with an integrated practice management system it can help generate a claim by pulling data that was entered into the EHR.

Once the claims are generated it's easy to upload and submit claims from your pm system to the clearinghouse, and if they are integrated you should be able to upload multiple claims into the system at once. The automated processes within the system will catch most data entry mistakes compared to submitting manual claims through payer sites. A good system should also give you everything you need to track and report on all of your submitted claims so it's easy to stay on top of any denials.  

Want to test more of your claim filiing knowledge? Download our claim filing eBook! 

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Topics: Insurance Claims, Practice Management, EHR Software

Want more optometry practice management tips? Check out our blogs.