Paper claim forms such as the CMS-1500 should be a thing of the past, right?

After all, in our everyday lives text messages have taken the place of written letters and it's unlikely you'll see someone using a typewriter over a laptop. But, technology has left some vision plan processes behind. The plans like it that way, but for patients and providers it can be a pain. Let's take a look at paper claim forms, when you have to use them and why accuracy is so crucial:

CMS-1500 Form for billing purposes

The CMS-1500, also known as the Professional Paper Claim Form, is the universally accepted form by government insurance plans as well as most private insurance carriers. The form is utilized by health care providers to bill for rendering services and/or materials. This form is composed of 33 boxes that must be appropriately filled by the provider in order for the claim to process for reimbursement. Sounds easy enough, right?

However, according to Healthcare Information Management Systems and Society, 86% of healthcare mistakes are administrative. It only takes one error for a paper claim to be rejected. As most providers now operate through the use of electronic medical records (EMR), it has become easier for billing administrators to fill out CMS-1500 forms and electronically file claims. EMR auto-fills the information required in each section of the CMS form, but pre-populated data entry doesn’t always mean free of human error.

The leading claim rejection/denial reasons

  1. Missing Information: If you didn’t already guess it, missing information is the leading cause for rejected vision claims. Payers often deem a claim unacceptable when it's missing a date of service, a subscriber ID, modifiers or doctor signatures (i.e. stamps/initials). For instance, procedure codes such as contact lens fittings and retina screenings require a modifier that may result in a line item rejection. Thus, reducing the overall claim reimbursement amount if left out.
  2. Inaccurate Coding: Codes must be specific to diagnosis and conform with ICD-10 coding guidelines. A patient purchasing materials during their medical eye exam is a primary example of how a medical diagnosis could mistakenly get billed with materials. It is up to your billing administrator to ensure a refractive code is billed as the primary diagnosis for an eyewear claim.
  3. Untimely Filing: The length of time given to submit, re-submit, and appeal any denied claims will vary per insurance payer. Filing limits could range between 90 days, 180 days and 365 days. I cannot stress enough the importance of this rule in mind. A misinterpretation I experienced early on was that I thought the time limit would reset after a denial letter. In other words, after receiving a claim denial, I was under the impression I had another 365 days to re-submit a corrected claim. When in fact, the filing limit was 365 days from the date of service to submit a claim as well as any corrections within that time frame. It is ultimately up to the provider to stay up-to-date with changes to the payer limits on timely filing.

Why paper claims instead of electronic?

Believe it or not, there are quite a few scenarios in which paper claims are the only option for eye care providers (ECPs) to receive reimbursement. Unlike medical payers, some vision insurances do not have clearinghouses to electronically submit out-of-network claims. The good old-fashioned paper claim is the only option to submit for reimbursement in such cases. For in-network ECPs, paper claims are only necessary when submitting corrected claims and recently termed member policies. As long as the member had active coverage on the date of service, a paper claim is necessary for filing after their term date, since their policy can no longer be retrieved on the provider portal. Another popular reason on the list is medically necessary contacts. Recent updates in provider portals give ECPs the ability to submit medically necessary contacts electronically but there are still others that require paper claims.

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Strategies to avoid rejected/denied claims

In order to optimize your practice for success in claim payouts, I recommend a well-structured administrative plan. Coming from a small independent practice I have seen the difference between having an in-house billing administrator and third-party billing groups. Both bring unique strategies that maintain high payout rates, but it is up to the practice owner to determine which one is the best fit for the practice. In my experience, I have analyzed 2 things:

In-house billing

Having an experienced billing administrator in the office was an asset to the practice because that direct contact with your office staff aids in training solutions. When our billing coordinator found mistakes in which opticians erroneously collected the wrong insurance information or improperly selected the wrong insurance tab under the patient name, these errors were brought to the staff’s attention. Not only was our billing coordinator catching these mistakes and correcting them, but the issue was then addressed directly to the staff member. Our office successfully worked together as a team to ensure everyone was doing their part to prevent any issues for the insurance coordinator when it came time to bill for services.

Think about it: Every staff member plays a role in billing. From the moment a patient calls to make an appointment and insurance information gathering begins to your receptionists collecting patient insurance cards upon arrival to the doctor(s) coding services and your opticians creating the transaction for exam/materials. It was certainly beneficial having that person in the office because it provided training on both sides, which is how I first began to learn about the internal process of insurance billing.

Third-party billing

Typically this a group of highly skilled professionals who have extensive experience in effectively submitting electronic and paper claims. I say effectively because it took me at least a year to become fully knowledgeable in submitting paper claims. Paper claims take time and require extremely keen attention to detail by the individual reviewing the form prior to submission.

An advantage of having a third-party group is the effectiveness of re-submitting a claim for processing. I always consider what I like to call the “claim timeline,” which is the estimated time it takes to resolve a denied claim. It could often take several weeks to receive an explanation of payment (EOP), additional time to investigate the denial reason, mail out the corrected paper form, and finally wait several weeks for a response. If that response results in a second denial, an appeal is typically required as a final attempt for reimbursement. By the time my appeal was sent and received, you guessed it: I reached my timely filing limit. Most third-party groups are especially careful when it comes to certain payers and their “claim timeline.” Time management is key, especially since over the years insurance carriers are shortening those time frames for timely filing deadlines.

What does your revenue management cycle look like?
Submitting claims - and submitting them correctly - plays a major role in the revenue cycle.

Provider considerations for billing success

Whether small or large, your practice relies on insurance claims to generate revenue. However, common errors play a significant role in unpaid claims. As a provider, you have to consider the loss is not only in the unpaid claim but also the expense of re-working a claim. This includes payroll time, office supplies and time away from profit-earning duties.

With a few adjustments to the office workflow and the right technology, you can focus less on re-submissions and more on submitting your claims right the first time. Hopefully in the future, paper claims will be a thing of the past but as of now they are still present for ECPs and all we can do is implement the best approach to minimize errors. I understand now that paper claims are not difficult to complete, but they do leave several opportunities for human error. Therefore, having a qualified individual to watch and care for your “baby” is the only way you can accomplish running other parts of your practice.

The objective here is to weigh your options on which organized method is the best fit for your office. Because insurance billing requires a lot of responsibility, monitoring, care and attention. Consider the following pros and cons to a structured billing system for CMS-1500 paper claims. Would you rather:

  • Save budget cost by using an in-house billing administrator(s) but risk having a higher chance of human error if attention to detail is overlooked, which in turn could cost practices thousands in unpaid claims and write-offs. However, benefit from having a billing expert dedicated solely to your practice who can easily pinpoint and address internal issues.
  • Incur an additional expense for using electronic billing platforms but benefit from user-friendly data entry sections that revise and check for errors. Since third-party platforms have set billing processes in place, that expense may be worth the extra cost if it means leaving the task for a dedicated team of professionals.

Submitting paper claims could be a tedious task to tackle, but denied claims could become an even larger pesky problem. Not only does remedying them require additional time and resources, but they also delay incoming revenue—a situation that can be difficult for practices to navigate. Now that you have a better sense of how essential it is to submit a proper paper claim, consider taking proactive steps in revenue management to streamline billing processes and increase reimbursement.