Learn how to fix issues in your claims process and revenue cycle, lower turnaround, measure staff performance, the best KPIs for claims submissions, and more.
Erroneous, late, and never-submitted claims are a significant factor behind lost revenue in ophthalmology and optometry.
In ophthalmology, consistent timely claims submission gives you more time to correct or appeal rejected or denied claims before they age out.
And in optometry, corrective eyewear claims that are overlooked or submitted late can quickly result in a lost client and a negative review.
In this guide, you'll learn about:
There are four primary reasons that vision practices (including ophthalmologists, optometrists, and "two-door operations" that offer medical procedures and also prescribe and sell corrective eyewear) struggle to submit claims on time and error-free:
The billing process for optometry, which usually involves a queue or stack of printed invoices that office staff enter into payer websites manually to obtain authorization as time allows, has multiple potential points of failure:
Coding and billing for vision care is unique among medical specialties. As a result, even though most ophthalmology practices use practice management software (PMS) and electronic health records (EHR) systems that allow for specialty coding, the unique requirements for vision coding create additional opportunities for data entry errors.
All of these issues are compounded by staffing shortages and hiring difficulties in the vision care field.
Medical offices in every sector of healthcare are facing unprecedented challenges in retaining, hiring, and training support staff for a variety of reasons including retiring baby boomers, declining job satisfaction, and COVID-19-related problems, and vision practices are no exception.
Automating repetitive tasks like data entry and claims submissions can reduce errors, free up your best staff members, and make your claims submission process more efficient. revBot by Revival Health is a virtual worker that can perform these tasks three to five times faster than a human, doesn't make mistakes, and comes with an ROI guarantee.
Reduce your claims processing times and improve your revenue by identifying weak points, making a plan, and benchmarking your results. Here's how.
First, perform an informal audit of your revenue cycle to find areas for improvement.
Make a thorough list of problems and reasons for those problems. Set aside time to observe what's actually occurring and ask billing staff in-depth questions about the process.
Investigate these areas and any others that come up in your audit:
This is your opportunity to gather information before you make a plan.
Instead of problem-solving or offering detailed feedback or corrections at this stage, focus on obtaining as much information as possible. Ask your team follow-up questions that lead to helpful insights, but without "grilling" them.
When you finish gathering information on revenue cycle issues, you should have a detailed list of problems and their apparent causes. Now it's time to consider changes to your process, ideas for training improvements, and other ways to tighten up your revenue cycle.
Consider these three categories to guide your solutions:
Once you make an initial list of ideas, hold a staff meeting to discuss problems and their causes, share your suggestions, and solicit input and feedback from team members.
After you implement the changes, it's wise to meet quarterly to discuss new changes, results, and key performance indicators. Plan on 1-2 days of staff training per quarter to refresh, problem-solve, and cover any updates to standard operating procedures (SOPs).
If your staff is struggling to keep up with changes or you notice that everyone's not on the same page, consider creating a cloud-based central repository for SOPs using services with a Business Associate Agreement (BAA) for HIPAA compliance like:
You can create folders for each area of business that contains several short, simple documents with descriptive titles and a table of contents. This is easier to keep updated and more effective in general compared to email updates, word-of-mouth, or a printed SOP binder.
Measuring your claims submission times and other important outcomes allows you to obtain objective, ongoing data rather than rely on guesswork.
It's probably not necessary to do this at a baseline prior to addressing your practice's known weak areas and problems. Unless your claims process and revenue cycle are already running reasonably smoothly, you can simply wait for the initial improvements to take effect, then get your baseline stats at that time.
You can benchmark two different ways:
The most direct metric for turnaround time is the average successful submission time, which represents the amount of time elapsed on average between the patient visit (day of service) and successfully submitting the claim to the payer.
Important: it's vital to include rejected and resubmitted claims in the average to get the full picture. Be sure to "run the clock" from the day of service until any rejected claim is successfully resubmitted, then factor that into your average.
counting rejected and resubmitted claims in the overall average.
Of course, if your practice is waiting several weeks or longer to work rejections, your true average successful submission time is going to be much higher. Some practices believe they have a one-day average successful submission time, which is usually a red flag: they're neglecting to work rejections and aren't averaging them in at all!
Make a master list of key performance indicators (KPIs) to track, then delegate to a senior staff member to keep the KPIs updated and accessible.
Review them weekly so you have a grasp on current trends and can detect problems early, then go over the three-month report during the quarterly training update to review progress and set goals with your front office team.
Use these key performance indicators (KPIs) and checklists to shorten your claims turnaround times and optimize your revenue cycle.
Many offices have inefficient claims submission processes because of the need for manual export and data entry, lack of familiarity with vision benefits (in ophthalmology) or medical insurance (in optometry), and a lack of practice management and EHR integration with certain insurance platforms and payer websites.
Other factors including staffing shortages, training challenges, and failure to track important metrics like rejection rates and average successful submission times for claims can also contribute to inefficiency.
Vision practices can expect up to a 15-25% increase in revenue from improving their claims processing workflow, though it varies depending on how efficiently your office is currently running. Gains come from a higher rate of successful payments, fewer timely filing denials, better patient retention, and reduced need for collections.
A comprehensive approach to improving claims processing times includes automating the first and last steps of the revenue cycle, training your staff in best practices to manage rejections and denials and perform resubmissions, and creating checklists of SOPs so claims submission and other revenue-generating tasks are never overlooked.
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