From Claim to Reimbursement: Best Practices for a Smoother Eye Care Billing Process

Eye care practices face unique billing challenges that other specialties do not typically encounter. They have to navigate a dual-payer environment where services can be billed to vision plans, medical plans, or both. Routine eye exams, refractions, and eyewear are typically covered by vision insurance, while diagnostics and surgeries are covered under medical insurance. This split can create confusion on top of the already complicated world of billing and coding, leading to rejections or denials when claims aren’t properly routed. 

Not to mention, the coding process in ophthalmology  optometry billing is highly nuanced. Coders must be able to differentiate between routine and medical visits, ensure proper use of modifiers, and document medical necessity for diagnostic testing and surgeries. This adds to a heavy administrative burden on practice staff, especially when it comes to toggling between multiple systems for EHR, practice management, and a clearinghouse.  

According to the 2024 Medicare Improper Payment Fact Sheet, providers lost $31.7 billion to improper payments, with an overall error rate of 7.66%. Billing errors aren’t uncommon, and they cost time and money that today’s practices can’t afford to waste. 

To accelerate reimbursements and reduce rejections, practices should focus on developing a smooth, efficient, and error-free eye care billing process that minimizes frustration and allows staff to spend more time on patient care. In this blog, we’ll explore the best practices for doing so.   

Best Practices for Cleaner Claims and Fewer Rejections 

Verify Patient Eligibility Upfront 

Eligibility verification is the first step of the eye care billing process and is critical for reducing rejections. However, insurance verification is a significant pain point in eye care, and practices are seeking ways to streamline and simplify the process. For example, a patient may have a vision plan for glasses and contacts, but they’ll need to use medical insurance for an exam related to diabetes or glaucoma.  

According to Experian Health’s 2025 State of Patient Access Report: 

• 56% of healthcare providers say patient information errors are a primary cause of denied claims. 

• 22% of patients experience care delays due to insurance verification issues. 

• 83% say there’s an urgency to improve or implement faster, more comprehensive insurance verification. 

• 45% of providers are automating insurance lookup and eligibility verification. 

Best practice: Verify eligibility at scheduling and again at check-in. Confirm which payer covers the service that the patient is visiting for, and where prior authorization is required. Furthermore, by adopting tools that automate this step or integrate eligibility checks directly into your scheduling system, you can prevent denied claims and avoid surprises for patients.   

Standardize Documentation and Coding 

Accurate documentation and coding are crucial in optometry billing and ophthalmology billing, but they can become complicated quickly. CMS found that roughly 60% of improper payments in fiscal year 2024 were due to insufficient documentation, and 10% due to coding errors. When looking at Medicare Part B services, projected improper payments for eye procedures like cataract removal and lens insertion totaled $296,715,219. This represents a 14.4% improper payment rate, with 90.6% of the improper payments resulting from insufficient documentation.   

What causes these errors? Common mistakes include: 

• Failure to differentiate between routine and medical visits. Billing the wrong insurance for the services provided leads to automatic denial. 

• Not applying the correct modifiers. This is especially prevalent when coding and documenting ophthalmic tests and bilateral procedures. Missing modifiers or incorrect bundling causes many denials. 

• Insufficient documentation of medical necessity. Reimbursement for specific procedures, such as visual field testing and diagnostic imaging, is only applicable when the procedure is deemed medically necessary.    

Best practice: To avoid denials due to insufficient documentation, it’s important to develop internal documentation checklists for procedures, ensuring all relevant details about the patient’s symptoms and diagnosis are included. Practices should also ensure that staff and providers are properly trained on differentiating between routine and medical visits, modifiers, and any updates in Medicare coverage policies. 

Explore our comprehensive guide on optometry billing and coding for more tips. 

Scrub Claims Before Submission 

Every denied claim means lost time and money. It’s essential to enhance your first-pass acceptance rates by identifying and correcting errors before claims are submitted.   

Best practice: Implement a scrubbing process, encourage staff to adopt a “get it right the first time” mindset, and set goals for improving your first-pass acceptance rate. Investing in a claims scrubbing tool helps your staff by providing an extra layer of protection, as it reviews claims for errors, inconsistencies, and compliance issues before submission through your clearinghouse.   

Closely Track, Analyze, and Manage Denials 

Regardless of how solid your eye care billing process is, denials can still happen. However, they don’t have to derail cash flow. The key is to closely track, analyze, and manage denials so you can identify patterns, correct issues, and continuously improve. 

Best practice: 

Monitor denials by insurance type, payer, and reason. Are certain services or procedures often denied? Are specific payers frequently rejecting claims? Monitoring denials and trends will help you uncover gaps in staff knowledge and workflows. For example, ophthalmology practices often face denials from Medicare, particularly for services such as visual field testing and OCT. This is largely due to missing or insufficient documentation, incorrect use of modifiers, and a lack of medical necessity. 

Practices should also create a standardized workflow for managing denials. It’s essential to promptly identify the issue, correct it, and resubmit through your clearinghouse to prevent further delays. Ideally, staff should investigate and correct denials within 24 to 48 hours.   

Speed Up Reimbursement Cycles 

Delays in payments can cause financial strain, especially for ophthalmology and optometry practices. Accelerating reimbursements improves cash flow. 

Best practices: 

• Submit claims daily rather than batching them every few days or once a week.  

• Regularly follow up on overdue claims.  

• Monitor key metrics, such as First Pass Resolution Rate (FPRR), Net Collection Rate, and Days to Payment, and set goals for improvement. 

Adopt an Integrated Billing Solution 

Even with the strongest processes in place, the wrong technology can hold practices back. When staff have to toggle between their EHR, practice management system, and clearinghouse system, errors and friction occur. 

Best practice: Adopt an integrated billing solution that handles eligibility checks, claim scrubbing, submission through your clearinghouse, denial management, and payment posting, all inside your existing practice management platform. This eliminates duplicate data entry, reduces workload, and frees up staff time to focus on patients. A modern, integrated billing solution leads to fewer rejections, better cash flow, and reduced admin work. 

Sightview’s billing integration, powered by TriZetto, helps practices streamline the entire claim cycle. Automated eligibility checks and connected workflows mean cleaner claims, fewer rejections, and faster reimbursements, right inside our all-in-one eye care platform.  

Putting it All Together: The Ideal Eye Care Billing Process 

When putting together the best practices for optometry billing and ophthalmology billing, what does the ideas process look like from eligibility verification to payment reconciliation? 

1. Eligibility is verified at scheduling and check-in. 
2. Providers document visits and procedures using a standardized process.  
3. Staff build strong claims with proper coding, modifiers, and documentation. 
4. Claims are scrubbed for accuracy before submission through your clearinghouse. 
5. Claims are closely tracked, and if denials occur, they're promptly corrected and resubmitted. 
6. Key trends and metrics are monitored to identify areas that need improvement.  

By following this process and leveraging an integrated billing solution, staff end up spending more time with patients and less time managing claims. 

Cleaner Claims = Faster Payments and Less Admin Strain 

Eye care billing isn’t easy, but with best practices in place, you can turn billing from a source of frustration into a reliable process that accelerates cash flow for your optometry and ophthalmology practice. The result? Your team can focus more energy and time on delivering high-quality patient care.  

With the Sightview platform, billing becomes simpler and smarter for practices leveraging our integration with TriZetto. Automated checks, cleaner claims, and faster reimbursements mean less admin work for your staff and a healthier revenue cycle for your optometry or ophthalmology practice. 

Request a demo to see how Sightview streamlines billing and helps your practice thrive.