October 27, 2023

How To Prevent Vision Insurance Rejections & Denials: A Guide

Seemingly small inefficiencies in your claims filing process can cost your practice a surprising amount of revenue. Here’s how to identify and fix those weak spots.

How To Prevent Vision Insurance Rejections & Denials: A Guide

Many optometrists and ophthalmologists miss out on a substantial sum of revenue due to rejected or denied vision insurance claims. Even if such claims eventually get paid, they may have to be resubmitted or appealed multiple times. That can interrupt cash flow, delay care, and lead to friction with patients.

Inefficiencies in the claims submission process can also be incredibly frustrating for practice staff. Mind-numbing claims workflows pull employees away from more meaningful jobs, like communicating with patients and bringing in new business. (In the revenue cycle management business, we often say it’s the doctor who buys a software system, but the staff who cancel it.)

Fortunately, many failed claims are entirely preventable. In this guide, you'll learn the underlying reasons so many practices struggle to achieve acceptably low rates of rejections and denials, as well as reliable methods you can use to lower yours far below typical industry levels and improve your bottom line.

How To Think About Rejections and Denials in Vision Insurance

Many providers talk about insurance rejections and denials in the same breath. However, understanding the distinction is essential if you want to get paid consistently.

A rejection is a claim that didn’t make it through the front door, so to speak. As far as the insurance company or managed vision care (MVC) network is concerned, it was never properly submitted. Typical reasons include errors with a patient's personal information such as name or date of birth, or an incorrect or expired policy number.

In contrast, a denial is a claim that was reviewed and was considered unpayable. This could mean that the service was coded incorrectly, the product or procedure isn’t actually covered by the policy — or the submission deadline has passed.

In other words, rejected claims can be resubmitted, but they may turn into permanent denials if the clock runs out. Understanding why these errors happen can be critical for limiting wasted time, contentious interactions with patients, and lost revenue.

Ultimately, reducing your rejections and denials requires viewing claims processing as a constant, high-priority maintenance task, not as an afterthought. But quite often, rather than prioritizing claims processing, practices neglect this essential area.

The Negative Impacts of Excessive Rejections and Denials

High rates of rejections and denials for vision insurance claims will hurt an eye care practice both financially and reputationally. . The most direct and obvious harm is lost and delayed revenue. The more time it takes you to get a claim submitted, the longer your invoice remains outstanding. Every rejection draws that process out further, increasing the odds that you’ll miss the deadline for submission, or that a competitor will claim the benefit instead.

If a claim is outright denied for reasons other than a coding error, your only remaining option may be to bill the patient. And sending an invoice is no guarantee that you’ll get paid. After all, it’s not like you can repossess someone’s eyewear.

Preventable rejections and denials can also strain your relationships with patients. Calling someone for information they’ve already provided, or billing them for a service they thought was covered, can lead to serious frustration. Each headache of this kind increases the risk that a patient will take their business elsewhere, perhaps leaving a negative review of your practice on their way to a competitor’s door.

A poor strategy for managing claims will increase the amount of tedious and time-consuming work for your staff. It also leaves them with less time to tackle the tasks that help your practice grow. You want them booking appointments, tidying the office, checking in patients, and selling glasses — not resubmitting a rejected claim for the fourth time.

Driving Factors Behind Unacceptable Denial and Rejection Rates

In a perfect world, every patient’s benefits would be pre-verified and every insurance claim would be carefully double-checked for errors before submission. In reality, achieving this level of thoroughness can be difficult due to factors like:

  • Overstretched staff. More demands on a biller’s time mean more chances to make mistakes. With the entire vision care industry facing staffing shortages, this problem is only becoming more common.
  • Prioritizing patient-facing tasks. Helping patients always feels more urgent than data entry. This can lead to claims submissions getting pushed off until later — and then completed in a hurry.
  • Walk-in appointments. Pulling benefits ahead of time is considered best practice. But it may not be possible when your business model involves new patients showing up and being seen immediately.
  • Specialization. Staff at an optometry-focused practice are often less familiar with the medical insurance billing process, causing errors with claims for things like glaucoma-related eye exams. Ophthalmology specialists may have the same problem when they have to file with managed vision care (MVC) providers for eyewear, vision exams, etc.
  • Convoluted fee schedules. MVC plans often include various discounts that must be applied when calculating patient responsibility. These benefits are notoriously convoluted, leading to errors in interpretation. For example, a biller can get so caught up in calculating the discounts on a set of lenses that they don’t realize the frames aren’t covered.
  • New tasks jump to the top. Correcting and resubmitting rejected claims is a crucial task, but it can fall by the wayside as newer business piles up at a busy practice.
  • Failure to use tech integrations. Many practice management systems (PMS) can interface directly with insurance and vision care systems to reduce errors. However, practice staff may not know about these capabilities or understand how to use them.

You can sidestep many of these issues by automating the most frustrating and time-consuming parts of the job. revBot by Revival Health is a customizable virtual assistant that can perform tasks like pre-certifying benefits and submitting vision care claims 3-5x faster than a person. Letting AI handle your repetitive data entry tasks can free your best staff up for higher-skill work.

Rejections and Denials: Optometry vs. Ophthalmology

Individual practices may be more or less affected by the problems above depending on whether they focus more on optometry or ophthalmology. One reason is that claims submission is less standardized and centralized in vision care than medical insurance.

While most health insurance claims can be submitted through a single digital clearinghouse, MVC networks all have their own systems. If one patient has coverage through Spectera, another has VSP, and another has EyeMed, your biller will have to go to each website separately.

As a result, the process is often done manually, with a staff member keying in data from printed invoices. That makes billing for optometry more time-consuming, more frustrating, and more vulnerable to human error.

Patient retention can also be more tenuous for optometrists, who tend to have more direct competitors. In addition, a patient may feel less loyalty to the doctor they see for eyewear prescriptions than the one who performed their cataract surgery.

On the other hand, MVCss have far fewer diagnosis and procedure codes than medical insurance systems. Procedures and products also don’t need to be deemed medically necessary to qualify for MVC reimbursement. As a result, denials for successfully submitted claims are relatively rare for optometry services — they’re much more common in ophthalmology.

How Your Vision Practice Can Reduce Rejections & Denials and Ensure You Get Paid

With all of the challenges vision care staff have to juggle, it’s no surprise that rejections and denials can pile up. But following a few simple best practices can help ensure that claims get processed, approved, and paid out in a timely fashion.

Get Prior Authorization 3-5 Days Before An Appointment

Has your patient’s insurance lapsed? Is the service they’re seeking covered? Have they already used their benefit for new lenses this year?

If you’re not pre-certifying benefits, you won’t find out until you try to submit a claim.

It’s best to do this well in advance. Patients don’t want to get a call the day before their appointment — after rearranging their schedule and taking time off work — informing them they don’t have coverage.

Instead, make a point of getting prior authorizations at least three days in advance of the appointment date. Adopting the following standard operating procedures (SOPs) can make it easier for your staff to stay consistent:

  • Whenever possible, pre-authorize benefits at the time an appointment is scheduled
  • Dedicate 30 minutes or so each day to running pre-authorizations (do this outside patient visit hours to minimize interruptions)
  • Review the schedule 3-5 days out and pull benefits for any patients not yet pre-authorized
  • Check daily for last-minute additions to the next day’s schedule

One benefit of adopting these solutions is that you'll notice significant improvements in patient flow and satisfaction. And prior authorizations will also alert you ahead of time to inaccurate information that could lead to a claim rejection, like transposed digits in a DOB, or a legal name that’s since been changed.

Submit Claims Immediately After Appointments

Many practices lose out on revenue by dragging their feet on claims submissions. The longer a claim ages without being filed, the greater the likelihood that the deadline for filing will slip by, leading directly to a denial. Most MVC plans begin issuing timely filing denials just 60 days after the service date.

The relevant benefit amount could also be used for something else while you’re waiting to submit. This is an especially common problem for two-door practices. A patient might visit your office for contact lenses, then head to the optical center next door for glasses, not realizing their plan only covers one or the other.

In that scenario, whichever office submits a claim first will get the insurance payment. Large optical retailers usually win these races, because they tend to use automation tools that can push claims through immediately after appointments. Some patients may even deliberately file duplicate claims at different service providers hoping to take advantage of filing delays.

Ideally, you should start the claims submission process the moment a patient walks out the door of your practice. Staff may struggle with this policy at first, especially when dealing with back-to-back appointments.

The answer to these types of issues often comes down to training. Establish a clear workflow and ensure that your billers understand the importance of submitting claims promptly. Or take advantage of automation software solutions like revBot by Revival Health so your best people can use their valuable skills elsewhere.

Work Your Aging Claims File Regularly

Errors are bound to happen, so reviewing unpaid claims should also be a high-priority, routine task at your practice. Don’t wait for a drop in revenue to address potential issues with your aging file!

You’ll find that many of your rejections and denials are due to easily fixable errors like typing mistakes or the use of an outdated code. Correcting and resubmitting them may be all that’s needed to get paid for the work you’ve done.

Commit to performing a full, comprehensive review of your aging claims file every 30 days. Because most MVCs work on a 60 day timely denial schedule, this should ensure you never let another claim expire.

Here are proven strategies that will  improve how your office handles of aging claims in general:

  • Create checklists of standard operating procedures to ensure all important steps are followed for each claim, such as: verifying National Provider Identifier (NPI) and Taxpayer Identification Number (TIN) for each payer; identifying referring/ordering provider, when necessary; and including Clinical Laboratory Improvement Amendment (CLIA) waiver number, when appropriate.
  • Make sure the appropriate staff are familiar with the timely filing deadlines for different payers.
  • Sort claims by payer submission deadlines and prioritize those about to age out.
  • When resubmitting denied claims, always reference the initial submission using the identification number from the remit — denials for duplicate submission are the most common type in vision care.
  • If you’re using a clearinghouse software, pay attention to the rejection reports it generates to learn what kinds of errors are happening most often (and, when necessary, retrain your staff accordingly).

The big takeaway here is that you must adequately address the aging file in terms of policies and procedures, training needs, and employee time allocation.

Even the smallest practices should budget at least 2-3 hours per week for billers to review and work the aging file. Large practices may need significantly more time — but working the aging file is always an excellent use of staff time because it directly improves your bottom line.

Stay On Top of Month-To-Month Coverage Changes

A patient’s vision coverage status can shift for a variety of reasons, including:

  • Job changes
  • Switching from one benefits plan to another
  • Missed premium payments
  • Changes in marital status
  • Changing HMOs (especially common with Medicaid patients)

If a patient schedules a visit near the start of the month, their coverage could lapse between pre-certification and appointment.

To avoid getting caught by surprise, practices should adopt the policy of double-checking prior authorizations on the 1st of each month. If any scheduled patients were pre-certified the previous month for a visit this month, this allows you to confirm their coverage is still up to date.

And it’s especially important to double-check prior authorizations on January 1, since beginning-of-year coverage changes are much more common than month-to-month.

You may already have some options you don’t know about — many benefits clearinghouses have integrations with practice management systems, allowing you to pre-schedule tasks like this. And once again, automation can make it much easier to achieve the consistency you need in this area.

Send Timely Patient Statements

Insurance won’t cover everything, and mistakes when calculating patient responsibility are going to happen from time to time. This means that sometimes you’ll have to bill for co-pays that weren’t collected during office visits.

When this occurs, it’s absolutely critical to send the statement as soon after the appointment as possible. Patients aren’t very good about paying bills after the fact, and the older the invoice is, the less likely it is to be paid.

But sending timely statements is only possible if you’re reconciling insurance payments in your system quickly and accurately. Your staff should treat logging insurance remits, calculating patient responsibility, and invoicing patients as a single, seamless process.

Benchmarks, Metrics, and Key Performance Indicators for Vision Insurance Rejections and Denials

Tracking your practice’s performance in handling rejections and denials is essential for establishing a baseline and achieving meaningful improvement.. The most successful vision practices will perform an internal audit at least once every quarter.

The following metrics, benchmarks, and KPIs are the most effective ways to track your performance in key areas of the billing process.

Rejection and Denial Rates

Most practices don’t even know exactly how many of the claims they file are rejected or denied. Yet these are some of the most important KPIs for evaluating your insurance billing processes. The two most important metrics to watch are:

  • Clean claims rate (CCR): This metric refers to the percentage of claims that are accepted without a single rejection and resubmission. Industry averages fall somewhere between 70% and 85%. Your goal should be 95% or higher.
  • Claims denial rate: The proportion of claims that are successfully submitted but then denied by the insurance company or MVC network. Denial rates of 5-10% are typical, while 3-5% is a sign of a practice that’s doing billing right.

Be sure to assess trends in these metrics and identify the underlying reasons for any shifts up or down.

Speed of Claims Submissions and Processing

As you may have noticed, many of the best practices for billing relate to getting things done in a timely, consistent fashion. Keeping an eye on the speed and efficiency of your processes will help you identify important weak points. Monitor the following KPIs:

  • Average time to successful submission: On average, how much time passes between your patient’s visit and a claim’s acceptance for processing by the payer? Including the time lost to rejections and resubmissions, your target should be an average of 2-4 business days.
  • Average time to initial submission: It’s also worth looking at how long it takes your staff to submit the “first draft” of a claim. You want the average here to be less than one day.
  • Days in AR: The average duration from the first submission of a claim to the receipt of reimbursement by accounts receivable. When cross-referenced with average time to successful submission, this tells you how much time is lost appealing denials. Most healthcare practices aim for 33 days, and anything lower than that is excellent.
  • Claims denied due to aging out: How many claims each quarter are denied because the timely filing deadline passed? Strive for zero!

Different insurance providers have different filing deadlines, so it’s often helpful to break these numbers down by payer. Billers working on aging claims should prioritize MVCs or insurance companies with shorter timelines. If that’s not happening, consider addressing it with additional training for billing staff.

Revenue Cycle Metrics

The following measures track your overall success at obtaining payment for services rendered. These are your practice’s vital signs.

  • Net collections ratio: The total amount of money you receive divided by the total amount of allowable charges. As with the processing time metrics above, you should also break this down by payment source for additional insights. A benchmark of 97% overall is ideal for this KPI.
  • Bills submitted to collections: How many invoices are you sending patients because they weren’t charged correctly during their visit? Your goal should be zero. When the number isn't zero, assess and figure out how to address the root causes with appropriate policies, procedures, and training opportunities.
  • Bad debt ratio: The percentage of allowable claims that have to be written off because you couldn’t collect from the insurer or the patient. 3% or less is a good benchmark to work toward. Many practices report rates of 9% bad debt or more.
  • Revenue per encounter: Your total revenue collected, divided by the number of patient visits. The target number will depend on your business model, but this metric is worth tracking no matter what.

Remember to account for the fee schedules of the individual payers you’re working with. What you’re charging may not be the same as what the insurance has agreed to pay. Too many practices don’t do this — they calculate expected revenue based only on their internal pricing.

It’s best to load your payer’s up-to-date fee structures into your PMS at least once per quarter. Otherwise, you can’t accurately assess how much revenue remains outstanding, which is critical information for a small business.

Closing Thoughts

Improving the efficiency of claims submissions will benefit almost every aspect of your practice.

Revenue and cash flow will improve as rejections and denials go down. Patients will be more satisfied with their experience. Staff members will be making better use of their time, and morale will improve with less repetitive work to do.

Most vision care practices can achieve major gains by consistently employing relatively simple practices like:

  • Pre-certifying benefits
  • Filing claims immediately
  • Adopting SOPs for working aging claims
  • Benchmarking and tracking submission times and denial rates
  • Automating workflow processes that computers handle better than humans

Optometry and ophthalmology practices always stand to benefit from optimizing their billing processes and addressing inefficiencies.. Implement these changes in your office, and you'll soon enjoy plummeting  rejection and denial rates and improved revenue that reflects the valuable work you do..

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