Best Practices for Clean Claims and Reducing Denials in a Retina Practice

Retina Coding

Retina Practice Management

Apr 1, 2025

Apr 15, 2025

Written By Elizabeth Cifers

Written By

If you manage billing in a retina practice, you know the frustration when claims get denied, rejected, or delayed. Every denied claim means lost revenue, additional work, and delayed payments, which strains the practice’s financial health and your team’s efficiency.

The good news is that most claim denials are preventable. That’s right – preventable. By implementing best practices for clean claims submission, your practice can reduce errors, improve reimbursement rates, and maintain a steady cash flow. Let’s dive into why claims get denied and how to fix the problem before it starts.

Why Do Claims Get Denied?

Developing strategies to avoid denials means you need to understand the reasons for the denial. Here are some of the main culprits:

Incomplete or Incorrect Patient Information, even minor errors, such as a misspelled name, incorrect date of birth, or outdated insurance information, can cause a claim to be rejected.
Missing or Insufficient Documentation is a common problem. If the documentation doesn’t support the claim, it can be denied. Payers require clear justification for billed services.
Medical Necessity Not Established is also a common reason for denial. Payers may deny a claim if they believe the treatment wasn’t medically necessary or the diagnosis doesn’t support the billed procedure.
Payer Policy Changes occur frequently. If your team isn’t keeping up with payer policies, you might bill for services that require prior authorization or are no longer covered under the patient’s policy.
Timely Filing Issues occur when claims are submitted after the deadline. Every payer has filing deadlines, and claims submitted after the deadline will not be paid.

Now that we have reviewed a few of the main culprits, let’s examine how to ensure clean claims and reduce denials.

1. Verify Patient Information at Every Visit

Accurate patient information is one of the simplest ways to prevent claim rejections. A small typo can lead to unnecessary delays. A few best practices include

Check insurance details at every visit.
Confirm the spelling of names, date of birth, and policy numbers.
Verify coverage at every visit to avoid billing inactive policies.

A quick verification process at check-in can prevent billing headaches down the line.

2. Stay Up to Date on Payer Guidelines

Payer rules change frequently, and what was billable last year or last visit might require prior authorization today.

Regularly review payer policies for your top insurance carriers.
Train staff on coding updates—hold monthly or quarterly refresher sessions.
Check prior authorization requirements before the patient is seen.

When coding aligns with payer rules, claims are cleaner.

3. Submit Claims Promptly to Avoid Filing Deadline Denials

Every payer has a deadline for claim submission, which means an automatic denial if you miss it. Some thoughts for preventing missing timely filing include

Submit claims within 24-48 hours of service delivery whenever possible.
Track filing deadlines for each payer and set reminders.
Follow up on unpaid claims before they hit the deadline.

A proactive approach ensures you never miss out on reimbursements due to late submissions.

4. Monitor and Appeal Denied Claims

Some claims will be denied despite best efforts. The key to resolving issues is quickly determining the reason for the denial and appealing (if appropriate).

Review denial reasons promptly and group common errors to address with staff as additional training.
Most payers have strict timelines for reconsideration, so file appeals quickly.
Track claim statuses monthly. Don’t wait months before checking, as the reconsideration timeline may pass.

A good denial management process turns rejected claims into paid claims or learning opportunities for what not to do.

5. Train Your Team

Billing and coding aren’t just administrative tasks for the billing team but for everyone who touches patient information. Staying abreast of the coding and billing rules requires continual learning and attention to detail.

Provide ongoing training for the front desk, billing, and clinical teams, including the physicians.
Hold team meetings to review claim trends and discuss best practices. A monthly staff meeting can be a quick and easy place to do this.
Encourage open communication between the physicians, scribes, technicians, and billing staff, which allows the billing staff to clarify documentation questions easily.

Denial rates drop when everyone understands their role in clean claim submission.

6. Ensure Complete and Accurate Documentation

Payers may deny the claim if your documentation doesn’t fully support the services billed. Ultimately, the physician is responsible for the documentation.

Clearly document medical necessity by explaining why the service was required. The documentation doesn’t need to be wordy or long – it can be concise but must relay the information.
Ensure diagnostic tests include a separate interpretation and report. How did the test affect the treatment plan?
Avoid cloned chart notes. Each visit should be specific to the patient’s condition that day.

The more straightforward your documentation, the fewer denials you’ll face.

Final Thoughts: Proactive Billing = Fewer Denials

Submitting clean claims isn’t just about reducing denials and getting paid faster. It’s about running an efficient and profitable practice with minimal disruptions. By implementing strong verification, documentation, coding, and auditing processes, your retina practice can reduce the number of denials and the corresponding need to rework the claim, improve your cash flow, and reduce your compliance risks. A proactive approach to claims submission means less stress, more efficiency, and a healthier bottom line.

Retina practices that regularly experience claim denials or delays may benefit from routine chart audits and coding and billing training. If you would like an expert opinion on the validity of your medical claims, please contact retina practice consultant Elizabeth Cifers. Elizabeth has decades of experience in medical coding and billing, including 13 years at a retina practice and a position at a leading eye care consulting firm. Book a free 30-minute call here.

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