Coding and Billing

What is the Most Important Thing You Can Do to Prevent Third-Party Denials?

By Mark Wright, OD, FCOVD,
and Carole Burns, OD, FCOVD

Sept. 1, 2021

Third-party claim denials can cost your practice significant revenues, cutting into your profitability. Here is the most important action you can take to stop those denials from happening.

The answer to the question of how best to prevent third-party denials is to check patients’ benefits before the day of the exam. This process requires you to use accurate data to access the patient file at the third party. If you are using any data that does not match the data the third party has, you will not be able to access the patient benefits.

If you are using nicknames or any name instead of the patient name showing on their third-party card, or if you enter a different birth date than what the third party has in its data, you will not be able to access the patient’s benefits. And if you cannot access the patient’s benefits, then when you bill for today’s patient visit, the claim will be denied because the billing information is incorrect.

The time to check patients’ benefits is before the patient comes to the office. One of the worst situations to occur is for a patient to show up at the office for a scheduled exam, and then when staff checks their benefits while the patient is standing at the front desk, the team member has to inform the patient that they have no current coverage.

Most patients will not keep the appointment. They will simply leave the office without completing the examination. This situation leaves the patient without care and your office with an opening in your schedule that generally cannot be filled. Had this problem been discovered a week before the appointment (or longer) then the patient could have rescheduled and the office would have had enough time to fill the appointment with a patient with current coverage or a self-pay patient.

By checking the patients’ benefits before the exam, you are giving your optical team advanced knowledge about the patients’ benefits. This answers questions the optical team is going to be asked such as what is “covered” and what are going to be my out-of-pocket expenses? By finding the answers before the patient visit occurs, this reduces the time patients spend in the optical and enhances the patient experience because patients are not having to wait while the optical team researches the answers.

Take this week to make sure that your team is checking patient benefits before the day of the exam by actually accessing the patient’s benefit file at the third party. This will help both your optical team and your billing team.

Photo credit, top of page: Getty Images

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