Jul 17, 2024
Apr 15, 2025
Written By Elizabeth Cifers
Are you noticing a pattern of denied medical claims or reimbursement delays at your retina clinic? The back-and-forth with payers is taxing on practice resources. But how can you minimize delays during a pre-pay audit or when you receive a denial on a legitimate medical claim?
We recognize that some payment delays are out of your hands. However, there are a few ways to ensure the maximum efficiency of the claims process.
Denials, primarily for drug reimbursement, are among the most common denials of valid medical claims. The payer will deny the claim even though everything is correct: diagnosis code, National Drug Code (NDC) number, procedure code, and eye modifier. Additionally, pre-authorization approval is on file, and criteria for try-and-fail are met. These denials may leave you frustrated, but if there are no issues with the coding and the documentation is supportive, you can appeal the denial. You would be surprised how many practices accept what the payer says without questioning the denial's validity and write it off.
Another example is a unilateral injection, which may be denied with a bilateral diagnosis code. Technically, if you treat both eyes but not during the same visit, the bilateral diagnosis code is correct, so it could be argued that it is accurate. However, you may avoid future denials if you bill with the appropriate unilateral diagnosis code corresponding to the eye injected on the service date. As always, the documentation in the chart must support the diagnosis and procedure codes billed.
Have you ever had a payer deny the claim for an incorrect NDC number? If you review the NDC number from your inventory management system, which is the same as the one submitted, it is most likely a valid claim. If all coding and documentation are correct and supportive, appeal the denial. Verify that the payer accepts 11-digit, not 10-digit, NDC numbers just in case the format was incorrect. If the NDC number needs updating, revise it and send in the corrected claim to appeal the denial.
Of course, there is a possible scenario where the claim is appropriately denied. The most recent and now common reason is when the physician switches from one drug to another without clearly documenting the medical necessity for the change. Whether it is a Medicare Administrative Contractor (MAC), Medicare Advantage, or commercial payer reviewing the claim, the medical necessity must be explicit, or (at least) it must be easy to follow the ‘why’ of the drug switch.
Additionally, some payers may have try-and-fail criteria for the first drug, which must be met before switching to the next drug choice. In both instances, unfortunately, if no one is watching closely for these scenarios, the physician has administered one or more injections of the new drug by the time the payer has denied the first one. This can be costly for branded drugs or at least an unsound practice for relatively inexpensive drugs. Regrettably, if you go back to the medical record and the documentation does not support the claim—you can’t change it—all you can do is learn from it and move on.
Need help verifying the validity of your medical claims, or putting the procedures in place to ensure proper documentation? That’s where a coding and billing consultant can help. Book a free call with retina practice consultant Elizabeth Cifers here.
It goes like this…
The payer asks for the medical record, so you send it per the payer's instructions. A few days (or weeks) later, you receive a denial stating they never received the medical record. You appealed and sent the records again, but you confirmed that the payer received them this time. The payer then denies the claim, stating the medical necessity for the service, procedure, or drug isn’t supported. You check the medical record, confirm the medical necessity is documented and supported, and appeal again. Or maybe you can get the opinion of an expert consultant to verify that the documentation is supportive and appeal again. Finally, the claim is paid.
When you receive reimbursement, it’s 6-9 months (or more!) after you originally submitted the claim. Sadly, this is an all-to-common scenario.
One of the most important things you can do to ensure an efficient claims process is to get it right the first time. Confirm you’re documenting and coding properly and meeting payer requirements for medical necessity, pre-authorization, or try-and-fail. Respond promptly to payer inquiries for medical documentation. If they deny it and you’re confident your claim is valid, don’t take no for an answer—get on the phone and talk to someone.
Retina practices that regularly experience claim denials or delays may benefit from routine chart audits and coding and billing training. For an expert opinion on the validity of your medical claims, 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 call here.
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