Feb 18, 2025
Apr 3, 2025
Written By Elizabeth Cifers
Staying informed about payer policy changes is essential for maintaining steady revenue, avoiding claim denials, and ensuring compliance, especially in a retina practice where injections are commonplace. However, insurance policies continuously evolve, and failure to adapt can lead to reimbursement delays, revenue losses, and increased audit risks.
Insurance companies adjust policies for several reasons. A few that come to mind include regulatory updates, new medical guidelines, new medications or technology, fraud prevention, and cost containment.
Medicare and Medicaid regularly update policies and guidelines and publish changes to allow retina practices to prepare and adapt. When new drugs, devices, or technology become available, a payer’s policy or guideline is almost always updated to incorporate the new option. Frustratingly, private payers may or may not provide transparency about policy or guideline changes, which can be costly to the practice due to the chance you will inject a drug not knowing the policy change and risk denial of the claim.
All payers have policies and rules to detect and prevent improper billing—in other words, fraud prevention. Additionally, reimbursement rates and coverage criteria typically change as cost-containment measures.
These changes directly impact your practice’s ability to get reimbursed. The sooner you know about and adapt to the changes, the fewer claim denials and financial setbacks you’ll face. So, how can your practice keep up with policy updates, adjust billing practices accordingly, and prevent disruptions to cash flow? Let’s examine some best practices.
Subscribing to all payer newsletters, Medicare Administrative Contractor (MAC), and commercial and Medicare Advantage plans is a must. Understanding when payer policies change is the first step to staying compliant. As the electronic newsletters come out, to ensure you don’t miss any updates, immediately review the information specific to retina and any other policies related to your practice that indicate there were changes.
The newsletters will provide the necessary information, such as changes or updates to specific policies, coverage, new guidelines, and prior authorization (PA) requirements. Still, sometimes, the newsletters come out after a change has gone into effect, so there is no harm in reviewing the payer websites regularly for changes and updates. Assigning these tasks to a team member responsible for conveying the information is essential for timely information.
Keeping track of the various payer policies for drugs, frequency of diagnostic testing, and PA requirements can feel like a full-time job. When you find the information, it should be organized in an electronic centralized document where everyone who needs it can access it.
Assigning one or two staff members or creating a team who share the responsibility to find, review, and then update the tracking system is critical. When policies or requirements are updated, information should be shared efficiently. Monthly staff meetings should include updated information to allow for discussion of the changes and provide the ability to answer any questions or clear up confusion. Making policy tracking a routine part of the daily, weekly, and monthly billing tasks reduces surprises.
Payer coverage changes are usually unwelcome, as they may result in further restrictions on the choice of drug, requirements to use a drug of choice, or more step-edits, aka try-and-fail, prerequisites. There are many possibilities for the payer's ‘why,’ such as cost containment or ensuring appropriate utilization of high-cost drugs. However, the bottom line is that you have to work with and manage the changes.
Let’s use step-edits or try-and-fail as an example. The payer states that drug A must be used first for three consecutive months with minimal clinical response for disease X before the payer considers allowing the patient to receive drug B. The payer has given a guideline for the step-edit. The unclear part is ‘minimal clinical response,’ where the chart documentation is vital to support either a positive or negative clinic response.
The practice has complete control over the documentation in the chart. The physician must provide accurate and supportive information to confirm the treatment's effectiveness or show a suboptimal response. The supporting data includes the chief complaint, the exam findings, the diagnostic testing results and interpretation of the results, and the impression/plan, which must work in concert to support whether the drug is working, it isn’t working, or something in between. While not ideal, the payer has a stake in what treatment the physician provides. It’s what we have to work with. So work with it until it can be changed.
Many payers will provide a PA, but the fine print also states that the PA doesn’t guarantee payment. It is imperative to know whether the diagnosis code is supported in the chart, whether the drug is on-label, whether the drug doesn’t have step edits, and if it does, whether they have or have not been met, how many doses per year per eye, blah, blah. You know the drill.
Payer criteria for PA for retina treatments can (and do) change frequently. Retina practices face challenges staying on (and not falling off) the PA hamster wheel. Some common PA issues include:
Staying ahead of PA updates is critical to ensuring the practice doesn’t have to absorb the cost of the drug due to failure to receive payer payment or the patient's inability to make the patient responsible. The policy tracking system is vital for all injectable criteria, and using the tracking system is equally important.
Payer policy changes often lead to unexpected denials, especially if your practice isn’t aware of the new rules. Although there is a certain amount of redundancy, it can be cost-saving if you re-verify PA requirements the day before the injection is scheduled, especially when the check was done in a different month, for example, the patient is coming in on the 5th of the month and the PA check was performed on the 24th of the previous month. Additional staff hours can be worth it if you catch policy changes before the drug is injected.
Sometimes, payers get it wrong, so if you believe a claim was improperly denied under a new policy, appeal the denial promptly. Additionally, know when the change occurred if you are appealing a claim service date before the new policy – payers have been known to apply new policies to old claims. A pre-emptive way to find payer policy changes can reduce reworking claims and speed up reimbursement.
Payer policy changes can disrupt your revenue cycle, but with a proactive approach, you can minimize denials and increase financial stability. The key to success? Never wait for a denied claim to inform you about a policy change—stay ahead of the curve!
Has your retina practice ever experienced a pattern of drug denials? Retina billing consultant Elizabeth Cifers, MBA, MSW, CHC, CPC, can help you start to catch errors that result in denials before they go out the door. With decades of industry expertise—including 13 years as a retina practice administrator and a role at a leading U.S. eye care consultation firm—Elizabeth has seen it all. She can quickly identify issues that may impact reimbursement. Schedule a free consultation with Elizabeth here.
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