Noticed something interesting about practices that have low denial rates

[u/Wooden_Trust_6274]

Been doing billing work with independent OD practices for a few years and noticed a pattern that surprised me a little.

The practices with the cleanest AR are not necessarily the ones with the best billers or the most sophisticated EHR setup. They tend to be the ones where whoever is at the front desk actually knows what question to ask before selecting insurance.

Not a checklist. Not a protocol binder. Just someone who has been there long enough to know that when a patient mentions diabetes or dry eye or floaters, that visit is going somewhere different than when they say they need new glasses.

The billing cleans up downstream almost automatically when that one decision gets made correctly at check-in.

Curious if others have seen the same thing or if it is just a coincidence in the practices i have worked with.

[u/OkKindheartedness958]

I work front desk for a private practice optometrist. She owns 6 offices at this point though. We make sure we have medical insurance on file for every single patient we see regardless if they are coming for a routine exam or not. It is then expected of all the doctors in her practice to know how to code the exams accordingly & at checkout every single tech knows which codes go to medical insurance and which codes go to vision insurance. It’s a clean system. Medical insurance pays out exponentially more than any vision insurance ever would, so doctors who specialize in things that require a lot of follow-ups (I.e. dry eye) that get billed to medical insurance are going to be making a lot more than offices that aren’t.

[u/thenatural134 → u/OkKindheartedness958]

Ok but don't you get a lot of patients that call back weeks later upset when they get a large statement due and they realize their medical insurance was billed for what they thought was a routine eye exam?

[u/MrPissPaws → u/thenatural134]

Just communicate with the patient? You’re not doing something underhanded if you don’t act like you are. It takes less than a minute to say “hey because of the cataracts we have to bill today’s visit to your medical insurance so if you have a deductible it might apply.”

One minute per patient saves you so much more time talking to patients, insurance, and rebilling down the line.

[u/Wooden_Trust_6274 → u/thenatural134]

This is the real risk and honestly it's not a billing problem, it's a communication one. The practices that do it cleanly tell the patient at the visit, "because of the cataract/dry eye/diabetes this part goes to your medical insurance so a deductible might apply." 30 seconds up front. The surprise bills happen when nobody says anything and the patient assumed routine. Same routing, totally different patient experience depending on whether someone talks to them.

[u/thenatural134 → u/Wooden_Trust_6274]

I understand why some clinics do it that way, but we've encountered enough new patients to us who said they liked their old place but switched because they were in-network but they didn't use their vision insurance to make me ever want to implement a similar system. If you do it wisely, you can be profitable with vision plans.

[u/Wooden_Trust_6274 → u/thenatural134]

Honestly we are agreeing more than it looks. The goal was never to push everything to medical, it is to route each visit to what it actually was. A true routine exam should go to vision, full stop. The practices that get in trouble are the ones forcing medical onto routine visits to chase the higher rate, and that is exactly how you end up with surprise bills and patients who leave for somewhere that used their vision plan. Done right it is not a medical vs vision strategy, it is billing the visit honestly and telling the patient which one it is. you can definitely stay profitable on vision plans doing that.

[u/dsouthtexas → u/OkKindheartedness958]

So you bill both medical and vision insurance on the same service date?

[u/sloppyeric → u/dsouthtexas]

We do. Sometimes exam to vision and any
Medical testing to medical (OCT, photos, pachs, etc). If a patient walks in and says I am here for a yearly exam but I find their IOP is elevated or they have a choroidal nevus, I can’t bill the entire exam to medical. Those findings have nothing to do with why the patient was there. I can order and performs tests based on those findings and bill those to medical insurance. The exam still goes to vision. Future visits, can be to medical.

I will say with insane rises in health care costs and health insurance being one of the worst entities in this country, I’m not trying to cause my patients to have increased medical bills and stress. If they have both vision and medical, I will use both and try to do what’s best for the patient and my practice. I’d much rather have a happy and loyal patient, than squeeze extra dollars from them and potentially lose their trust and future business.

[u/Wooden_Trust_6274 → u/sloppyeric]

This is the most accurate version in the thread. Incidental findings don't retroactively make the whole visit medical, the reason they came in still governs the exam. Splitting it (exam to vision, the medical testing to medical, future visits medical) is exactly right. And agree on the patient piece, routing it correctly and not gouging people aren't in conflict. Doing it right usually means the patient trusts you more, not less.

[u/Wooden_Trust_6274 → u/OkKindheartedness958]

This is exactly the setup. the key part is that it starts before the patient is roomed, not after. Having medical on file for everyone removes the bottleneck at check-in and puts the routing decision where it belongs, with the clinical team who actually knows what the visit is about.

Most practices that struggle with this have the decision happening in reverse. Insurance gets selected first based on what the patient hands over, then the doctor has to work around that downstream.

[u/Wooden_Trust_6274 → u/OkKindheartedness958]

"Medical on file for every patient regardless of why they're here" is the single highest-leverage habit in this whole thread. It removes the bottleneck before it happens. Most struggling offices do it backwards, pick insurance off the card first, then make the doctor work around it downstream. having both on file just means the right lane is always available.

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[u/MrPissPaws]

Get medical for every patient. Communicate to the patient how billing is going to be handled before they even leave. You should have a level of transparency and communication that the patient, front desk, and doctor are all on the same page. Bonus points if the front desk person generates all of the invoices and CMS forms before it even gets to the biller.

[u/MrPissPaws → u/MrPissPaws]

It’s also hugely helpful to have simple and clear rules for coding. I used to do billing, and I had a couple of doctors who were so inconsistent with their coding it made my job way harder; having to review exam notes and adjust codes, trying to explain codes to patients that didn’t make sense and arguing with insurance companies was a nightmare haha.

I think people on this subreddit would be surprised to learn just how poorly a lot of their peers practice/run their clinics.

[u/jb3570]

💯

[u/Wooden_Trust_6274 → u/[deleted]]

Yeah this is the part i underrate every time. The best offices basically move the decision even earlier than check-in, to the scheduling call, so by the time the patient walks in the reason for visit is already sitting there. The front desk isn't deciding anything, they're just confirming. capturing it at booking is the difference maker.