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  • Proper Coding Begins With Commercial Payer Policies, Part 1

    The ophthalmic billing world knows clean claims that follow payer policy are the fastest route to reimbursement.

    With electronic submissions and payment, the process can render a streamlined revenue cycle. When practices receive claim denials, brakes are applied and extra work (and delay) begins. Was it a clerical error? Was it related to payer policy? What is that policy?

    Here are some stellar tips to locate commercial payer guidelines:

    Identify the Participating Payers for the Practice

    The No. 1 rule in coding is: Who is the payer? Rules vary based on participation and nonparticipation. Understand that commercial carriers can have both open and closed networks within the plans they offer. Practice contracts will dictate which plans you participate in and which you do not (for example, HMO closed access, PPO open access). Feeling overwhelmed? Start with the top five.

    Access Your Contract to Verify Terms That May Be Unique to Your Practice

    During contract negotiations, terms of service and reimbursement can be altered, for example the timely filing deadline. Payer processing software does not always mimic the terms of your agreement. If denials occur, the contract should be referenced for the agreed terms. When management changes hands, for the practice or the plan, specific nuances often are overlooked, causing loss through claims processing and payment.

    Bookmark Payer Websites

    This tip is even more important once you locate where the unique policies are published. Commercial plan websites are commonly a challenge to navigate, sometimes requiring logins for participating providers. Guidelines can be found under categories like e-manuals, policies and guidelines, medical policies, utilization policies, prior review, preauthorization and notification lists, medical record submission process, coding guidelines, clinical guidelines, provider bulletins and many other titles. Do not assume the location will be apparent from the home page. Visit the sites frequently to monitor updates.

    Payer Policies Vary

    Lastly remember the second most important coding rule — never apply one payer’s rules or perceived rules to other payers.

    Reference Proper Coding Begins With Commercial Payer Policies, Part 2 to learn how to stay abreast of changes before they lead to revenue delays.