Ophthalmology Centers: Dealing With Claim Denials
Here an ophthalmologist and an insurance expert at an ophthalmology-driven ASC discuss procedures that have high denial rates as well strategies to deal with denials and whether insurance companies will continue to be particularly strict.
Question: Which billed ophthalmology procedures have the highest denial rates?
Robert Noecker, MD, New Vision Cataract Center, Norwalk, Conn.: The procedures that tend to be denied are those that are new, done infrequently or are done in combination with other procedures. For instance a routine cataract surgery is rarely denied.
On the other hand those procedures that have T codes are most commonly denied. Often it is a lack of familiarity with the procedure when doing newly-approved procedures. The first time the insurer may hear about it is when the claim is submitted from the ASC. In my area, newer glaucoma procedures like the express, canaloplasty and istents have had higher denial rates initially. Once the procedures lose the T code it is easier to get reimbursed but it is not automatic.
Other procedures done in combination, such as complex combined glaucoma procedures with cataract surgery may be considered a bundled procedure.
Kathleen Goich, Insurance Supervisor, Lakeshore Eye Surgery Center, St. Clair Shores, Mich.: Without question I-stents and Express shunts. We send more chart notes for these claims than any other procedures
Q: What effect do denials have on your surgery center?
Dr. Noecker: Denials obviously can lead to non-payment of devices. At a minimum, they increase the amount of money tied up in accounts receivable. This can affect cash flow, which can be problematic if there is no cash on hand to pay expenses.
This can affect the viability of the ASC and result in less profit for the owners. If denials are not caught in a timely fashion, the window for payment can close. Also if these are not monitored closely, repeat denials can occur on the same procedure with mounting losses if not corrected.
Q: What are some strategies your surgery center uses to deal with denials?
Dr. Noecker: We do regular audits to spot check payment for services. We try to do these on a monthly basis to ensure that if there are denials we either do what we can do to correct them or at least do not do more of the same procedures in the facility without an alternative plan for payment.
If a procedure is known to have been denied in the past, we try to obtain prior authorization from the insurer and while this does not guarantee payment, it increases the likelihood.
Also for some of the newer devices and procedures such as the Express or I-stent, the manufacturers have contracted with third parties to aid in prior authorizations or helping to clear up denials. We have found these to be very helpful in assisting with preventing and resolving denials.
Q: Is it useful to get the sales reps involved?
Ms. Goich: We get our sales reps involved as they continue to tell us that the devices are covered. Sometimes the [device] company appeals to the insurance companies however I rarely see that making any difference. In the case of Blue Cross of Michigan, the sales reps are told it is covered, but what they aren't told is that it's covered by one group of individuals and not across the board by all groups.
Q: Do you think insurance companies will become stricter regarding claims in the future?
Dr. Noecker: Yes, it seems to be a growing trend that patients will bear more of the cost of procedures in the future. We see more resistance to getting paid with newer procedures or procedures that are out of the norm. It seems to take longer for the newer procedures to gain acceptance at the payer level compared to years past.
Ms. Goich: Most definitely, as they continue to decrease the covered diagnosis that can be billed for a patient. For example, cataract surgery; insurance companies are narrowing down the diagnosis that they will pay for the procedure. In the past you could pick any cataract diagnosis that would match the condition and bill for it. No longer is that the case.
They are getting more and more difficult to deal with when it comes to diagnosing diabetic eye procedures.
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