Ophthalmology and Optometry Coding Alert

Question: We are having issues with one payer — they are denying all claims for glaucoma screenings, even though when we call their payer relations department, they confirm that we’re billing the right codes and have met the guidelines. When we file appeals they just come back denied, but we don’t have any explanation of the issue that might be causing the denials. What can we do?

Codify Subscriber

Answer: Initially, you should always attempt to resolve issues directly with a payer through their provider grievance department or their medical director. But it sounds as if you have tried those steps and you don’t seem to be getting anywhere, so in that case, your final step should be to enlist the assistance of your state’s medical society as well as involve your state’s insurance commissioner when necessary.

Since single complaints here or there from a single practice have less impact with the state, the medical society has the ability to aggregate multiple problems from practices throughout the state. So, by involving your state’s medical society and providing it with the data and problems you are experiencing with your payers, it can accumulate your data along with other practices’ data and then report that aggregated data to the state department of insurance.

You can prepare the payer by letting them know if you don’t get a satisfactory answer about the claim denials, that you’ll be contacting the state insurance commissioner by the end of the week. Hopefully this will spur them into action.

Keep in mind: Contacting the insurance department in your state should be a last resort step as it can lead to animosity that is not always productive when dealing with insurance companies you work with on regular basis.

Prolonged issues? If your practice seems to battle a particular payer over and over again, you might want to consider holding a meeting with the medical director for that payer and your physician to discuss the issues in dispute. If you cannot get the problem addressed and resolved, you may want to consider dropping that insurance company because your cost to collect a dollar is probably exceeding the payment of that dollar.

If your practice decides to no longer contract with a payer, be sure to check your contract and give the appropriate notice to the payer in terms of method (in writing) and sufficient notice as defined in the contract. Then you want to make sure that you also give sufficient notice to your patients if you are ending a relationship with a particular insurer.

Hopefully your grievance is resolved at the payer level and you don’t need to take those steps.