How Do I Get Paid as a Solo Practice Ophthalmologist?

One of the most confusing things for me as a new solo practice ophthalmologist was figuring out how to get paid. This topic strangely barely came up in my previous lives as a trainee and academic ophthalmologist. So when I went solo, I devoted a fair amount of time to figuring out our byzantine healthcare system filled with third party payers and industry jargon. 

A very helpful resource to get started is the American Academy of Ophthalmology’s Reimbursement 101 Guide. I will briefly go through the system briefly in the hopes that you will leave here less confused than I was. 

There are multiple times during the billing process that should be utilized to ensure that you receive enough money to keep the lights on and put food on the table. 

Step 1: Scheduling the appointment

Make sure that you are currently contracted with the patient’s insurance. I recommend having a list of every insurance plan you accept easily accessible to the front desk staff. If the patient says that they have a plan that only sounds close to one that you accept, you are out of network and he/she needs to pay cash to see you. 

Step 2: Check In

Upon check in, have the patient fill out a registration form that includes all their pertinent demographic and insurance information. You must make a copy of their current insurance card and photo identification as well. At this point, verify their insurance eligibility. Part of eligibility verification includes determining how much of a patient’s deductible is remaining. 

Step 3: The Patient Encounter

During the clinic visit, you will do what you’ve been trained to do: provide excellent care and document your findings/plan. Crucially, this is the best time to code your charges. If you don’t have a superbill, I suggest that you make one that the patient can bring back to the front desk or that can be built into your electronic medical record. 

Step 4: Check Out

This is your last high-percentage chance to collect what you are owed from the patient. During the patient encounter, your front desk staff will have verified their eligibility and be aware of whether or not their deductible has been met for the year (if they didn’t have time to do so during check in). If the deductible has not been met, collect your fee up to the deductible limit. If the deductible has been met, collect the copay if necessary. 

Step 5: Create the Bill

Create an itemized bill that can be easily translated into an insurance claim. This should be done by your front desk staff during check out so that you can give the patient an itemized receipt upon payment. Make sure that your fee schedule is greater than your highest-reimbursing payer’s fee schedule. 

Step 6: Create the Claim

The insurance claim is simply a standardized form with places to list patient information (demographics and insurance identification number), diagnosis codes, and procedure codes for which you are requesting payment. You can create the claim by filling the form out by hand or electronically. I use a practice management software that is part of my electronic medical record so that all the demographic, billing, and coding information automatically imports into the correct places on the form. 

Step 7: Send the Claim

If you use a clearinghouse, you will then send your claim to the clearinghouse. The clearinghouse will then verify that the form is filled out correctly and is in the proper format for the specific payer (a process called scrubbing the claim). The clearinghouse then sends on the claim if there are no errors detected during scrubbing. It gets “kicked back” to you if there is an error that needs correcting. 

Step 8: Receive the Electronic Remittance Advice (ERA)

The ERA is a form that is generated by the payer indicating every procedure code you submitted and whether or not they paid it. For every code that is denied, there is typically a denial code that will tell you why it wasn’t accepted. You should look carefully at this form and determine what (if anything) you need to correct prior to resubmitting the claim. 

Step 9: Get Paid

Time to party! If the claim was clean and your coding was done correctly, the funds should be hitting your bank account via electronic fund transfer (EFT) in 2-4 weeks or paper check in 4-6 weeks. 

Step 10: Adjust the Bill

Make sure your accounting stays up to date and adjust the billed amount to your contracted rate. If there are any outstanding monies due (e.g. an uncollected copay), send the bill to the patient. Be sure not to balance bill.

Beneath the Jargon

Here are some industry terms in plain English: 

• Fee Schedule. Your fee schedule is a list of CPT codes and how much you charge for each coded service. The payer’s fee schedule is a list of CPT codes and how much they will pay for each coded service. Your fee schedule should always be greater than the payer’s fee schedule to make sure that you maximize your reimbursement. If you bill less than your contracted rate, that’s how much you’ll get paid. If you bill more than your contracted rate, you’ll get paid your contracted rate. So make sure that your fee schedule is some multiple of your highest-reimbursing payer’s fee schedule. You will have to write off the difference between your billed rate and your contracted rate. 

• Clearinghouse. A middleman between your practice and each payer. A clearinghouse helps make sure that you submit your claims in the proper format and will hopefully catch errors before the insurance company does, ensuring more timely payment. 

• Claim. The insurance claim is simply a standardized form with places to list patient information (demographics and insurance identification number), diagnosis codes, and procedure codes for which you are requesting payment. 

• Balance Bill. The practice of billing the patient for the difference between your bill (from your fee schedule) and the contracted amount. This process violates the terms of your payer contracts. Don’t do this. 

• Advance Beneficiary Notice (ABN). A form that the patient signs indicating that they will receive a service that may not or will not be covered by their insurance. The patient is responsible for the entire financial burden. A classic example is having an ABN prior to performing FLACS with a multifocal IOL implant. The insurance company with cover the cataract surgery (66984) but not the use of the femotsecond laser or the specialty lens implant.