Make sure everyone knows their role

In this changing climate, physician practices must manage revenue differently to ensure that the value delivered to patients is paid for appropriately and accurately. For optometry practices to ensure their claims are paid, they must first understand how the different components of claims management affect reimbursement. Successful reimbursement requires optometry practices to consider and address how each of the components of patient-provider contact fit into the revenue cycle and potentially present gaps that lead to loss or risk.

In other words, improving reimbursement starts with assessing the current state of your “team.”

KNOWING THE PLAY

Successful claim-processing comprises skilled personnel and efficient processes across all areas of a practice. The administrators, billing managers, reimbursement specialists, and physicians are your team’s coaches. Receptionists, technicians, physicians, and billing are the players. The playbooks are Medicare manuals and policies, coverage updates, coverage policies from commercial plans, coding resources (ICD-10, HCPCS, CPT coding books), and internal tools, such as forms.

Each player has a role on your team to ensure proper and timely billing and reimbursement. Those roles and their responsibilities are:

• Receptionists
  • Capture insurance data (check whether all ODs participate).
  • Conduct prior authorizations and obtain referrals.
  • Are patients seeking routine care or medical care, and do they understand their responsibility for each.
• Clinical staff
  • Obtain an accurate chief complaint and history (review last note and appointment schedule for reasons for return visit, and interview the patient).
  • Obtain financial waivers and patient consent forms.
• Optometrist
  • Document indications for tests and test orders.
  • Proper documentation of test interpretation:
    • Physician order
    • Date performed
    • Technician’s initials
    • Reliability of test
    • Patient understanding and cooperation
    • Test findings
    • Assessment and diagnosis
    • Therapy impact, prognosis
    • Physician’s signature
  • Capture ICD-10 accurately:
    • Use the most descriptive ICD-10 code possible.
    • Correlate primary diagnosis with the chief complaint.
    • List chronic and secondary diagnoses if addressed at visit.
    • Code with symptoms, if no other definitive diagnosis.
  • Capture visit code correctly:
    • Do you have all the elements for an eye code? Comprehensive eye code (complete exam, including fundus photography, a test, and treatment), or intermediate eye code (abbreviated exam, new or worsening problem, and treatment)? Or would an E/M code be a better choice?
  • Conduct timely completion of clinical documentation.
  • Open communication with physicians and coders regarding documentation is crucial.
• Billing staff
  • Track and adhere to edits.
  • Conduct timely submission of claims to payers.
  • Review outstanding A/R balances.
  • Post denials and resolve them.
  • Engage in accurate payment posting.
  • Provide education and staff feedback.
• Management
  • Ensure communication and feedback for all players.
  • Monitor player performance.
  • Review revenue cycle metrics and trends regularly

Administrators should also cross-train staff to better understand the basics in each area, use job sharing, and work with other departments to fix claim errors.

TOUCHDOWN!

Reimbursement involves the entire office, from the call center, to the ODs, and depends on charting, medical necessity, and communication. Teamwork improves the chances of correct claims and winning the reimbursement game. OM

BRANDY H. SPERRY is an associate consultant for Corcoran Consulting Group, which specializes in coding and reimbursement issues for ophthalmology and optometry practices. Contact her at bsperry@corcoranccg.com or at (800) 399-6565, ext. 238.