For optometry Revenue Cycle Management, precision wins
See how small optometry practices are using NextAccel’s RCM approach to eliminate billing errors, reduce denials, and accelerate collections long before revenue problems become critical.
I still remember Christine, a practice manager at a three‑physician optometrist clinic, calling on a Friday afternoon. Her voice was tight. Claims that used to pay in ten days were now sitting for weeks. Payers were asking for more information. Denials were creeping in for reasons that felt embarrassingly simple. A missed eligibility check when the patient’s medical plan should have been billed instead of vision. An outdated prior authorization for OCT. A modifier 25 appended to an exam without documentation supporting a separately identifiable service that day. The team was working late, resubmitting claims, and fielding patient calls about surprise balances. Cash flow was thin. Payroll felt closer than it should.
(Modifier 25 scrutiny and correct usage are well documented for optometry and ophthalmology) AOA Coding Guidance, Ophthalmology Management
Christine did not need a lecture on revenue cycle theory. She needed claim processing to work. She needed every claim to leave the door clean, meet payer rules, and get paid the first time.
That focus is the heart of precision in optometry RCM. Precision is not fancy. It is the discipline to verify eligibility and benefits, line up coding with documentation, route prior authorizations on time for tests like OCT 92133 or 92134, visual fields 92083, and fundus photography 92250, then submit complete claims that meet payer rules. When claims are clean, denials drop and collections move.
Optometry billing focus areas
Why claim precision matters right now
Across the industry, initial denials rose in 2024 and payment timing slowed. Kodiak Solutions reported an initial denial rate of 11.81 percent and lower collection rates from insured patients, summarized by BusinessWire, Becker’s, and HFMA.
BusinessWire press release, May 21, 2025, Becker’s Payer Issues, HFMA analysis
Most denials are avoidable. Optum’s 2024 Denials Index found an average denial rate near 12 percent, estimated that 84 percent of denials are potentially avoidable, and showed that 44 percent begin on the front end with registration and eligibility issues.
Optum 2024 Denials Index PDF
Small practices feel the pressure twice. MGMA reported an 8 percent first‑submission denial rate for single‑specialty groups and found that 60 percent of medical group leaders saw rising denials year over year, often tied to eligibility errors and incorrect modifier use.
MGMA Stat, Mar 6, 2024
Documentation quality also matters. CMS reported a 7.66 percent improper payment rate in Medicare Fee‑for‑Service for FY 2024, with most errors tied to insufficient documentation rather than fraud.
CMS FY 2024 Improper Payments Fact Sheet
Automation creates measurable savings. The 2024 CAQH Index highlighted a 20 billion dollar opportunity by moving eligibility and claim status to fully electronic workflows.
CAQH Index overview, AJMC summary
In commercial markets, denial pressure is visible. MoneyGeek’s analysis of marketplace data showed nearly one in five in‑network claims denied in 2024, with most denials tied to paperwork or plan design rather than medical judgment.
MoneyGeek ACA denial rates
A real example of precision in optometry claim processing
In late 2024, a multi‑location optometry group asked NextAccel to take over claim processing within its RCM. The operation had a 5 to 7 percent error rate, daily bottlenecks, and inconsistent training. We rebuilt the claim pathways with documented SOPs, payer‑aligned quality gates for medical necessity and modifiers, exception handling, and root‑cause fixes. Within five months, submission errors dropped to zero and accuracy held at 100 percent. Monthly eligibility verifications rose from 330 to 760. Clean claim submissions scaled to 550 per month. Monthly claim value grew from 12,000 dollars to 105,000 dollars. These numbers reflect precision done every day, not a one‑time sprint.
What precision looks like in a small optometry practice
Eligibility and benefits first
Run real‑time eligibility checks for every visit. Confirm medical versus vision routing, member ID, deductibles, copays, and frequency limits for testing or eyewear. If the visit is medical, bill medical. If the visit is routine refraction and eyewear, bill vision. Stop claims at the front desk if coverage looks wrong. Refraction 92015 is often non‑covered by Medicare and many medical plans, so document patient responsibility or route appropriately.
AAO refraction policy and coverage guide, AAO Fact Sheet on Refraction
Clean claim submission
Map coding to documentation. Apply payer‑specific rules. Use quality gates to block claims missing notes, laterality, modifiers, or authorization proofs. Require clear documentation if you append modifier 25 for a separate exam on the same day as a minor procedure. Track claim status daily.
AOA Modifier 25 Guidance, Ophthalmology Management on proper use
Everything else supports these two steps.
The NextAccel way
We focus on the claim pathway from intake to payment for optometry.
- Eligibility checks before the visit, including medical versus vision routing and frequency limits.
- Prior authorization sent and tracked on time for OCT or visual fields when required.
- Coding lined up with documentation using the correct eye codes or E/M, laterality, medical necessity, and appropriate modifiers.
- A claim packet that meets payer rules the first time, with proof of authorization and complete documentation.
- Real‑time dashboards that show what is stuck and why.
- Audit trails that make every decision traceable.
- When a denial occurs, we do root‑cause analysis and fix the source so it does not repeat.
Optum Denials Index, MGMA front‑end training impact
This approach turns optometry claim processing into a reliable system rather than a scramble. It is not about more people doing more work. It is about building a pathway that does not leak.
What changed for Christine’s clinic
We set up eligibility checks for every appointment the day before the visit. Front desk staff had a one‑page checklist for member ID, coordination of benefits, deductibles, copays, refraction responsibility, and authorization requirements for OCT or visual fields. We mapped payer rules into claim quality gates, so claims would not move if documentation did not support coding, including correct use of modifier 25. A dashboard showed claim status and response reasons, with daily follow‑up tasks routed by priority.
AAO refraction coverage guidance, AOA on modifier 25 documentation
Within six weeks, the clinic’s first‑submission denial rate dropped to 3 percent. By the end of quarter two, denials were under 2 percent. Collections picked up. Patient calls about balances fell. The front desk was calmer, and the billers shifted time from rework to new claims. Cash flow felt normal again.
What the data says about doing this
- Optum found that 44 percent of denials start on the front end and that registration and eligibility issues are a leading cause.
Optum 2024 Denials Index
- MGMA polling highlights the same front‑end themes. Practices that reduced denials credited intake training, stronger eligibility verification, and tighter documentation.
MGMA Stat
- CMS shows that insufficient documentation drives most Medicare FFS improper payments.
CMS FY 2024 Fact Sheet
- CAQH quantifies the benefit of automation. Fully electronic eligibility and claim status checks save staff time and reduce manual errors that lead to denials.
CAQH Index
- In commercial claims, marketplace denial rates remain high and are often caused by paperwork and plan rules. Clean claims and correct benefit checks are the antidote.
MoneyGeek ACA denial rates
What changed for Christine’s clinic
We set up eligibility checks for every appointment the day before the visit. Front desk staff had a one‑page checklist for member ID, coordination of benefits, deductibles, copays, refraction responsibility, and authorization requirements for OCT or visual fields. We mapped payer rules into claim quality gates, so claims would not move if documentation did not support coding, including correct use of modifier 25. A dashboard showed claim status and response reasons, with daily follow‑up tasks routed by priority.
AAO refraction coverage guidance, AOA on modifier 25 documentation
Within six weeks, the clinic’s first‑submission denial rate dropped to 3 percent. By the end of quarter two, denials were under 2 percent. Collections picked up. Patient calls about balances fell. The front desk was calmer, and the billers shifted time from rework to new claims. Cash flow felt normal again.
If you lead a small optometry practice, start here
Fixing claim processing does not require a big transformation. It requires two daily habits and a clear view of the work.
Run eligibility and benefits for every visit. Resolve mismatches before a patient sits down. Decide medical versus vision routing up front. Document refraction responsibility when applicable.
AAO Fact Sheet
Submit clean claims only. Do not send a claim that fails a payer rule or lacks documentation.
Optum Denials Index
Everything else supports those two habits. That focus aligns with current industry data on avoidable denials and saves staff time that would otherwise be spent rewriting claims.
Optum Denials Index
The broader context
You can do this while payers change rules and ask for more information. Kodiak and Becker’s reported increases in initial denials and a growing use of information requests that slow payments. Your response is precision and documentation.
BusinessWire summary of Kodiak, 2024 data, Becker’s report on RFI use
Automation helps, and CAQH quantifies the benefit. Move eligibility checks and claim status inquiries to fully electronic workflows. That step alone reduces manual errors and shortens the cycle.
CAQH Index
Remember what CMS found. Insufficient documentation drives improper payments. Tighten your notes and coding. That is measurable and within your control.
CMS FY 2024 Fact Sheet
Claim processing is not a back‑office chore. It is the way your optometry practice gets paid. Precision wins when you validate eligibility, align documentation and coding, and submit complete claims that meet payer rules. Do that consistently and you will see fewer denials, faster collections, and less stress.
NextAccel helps small optometry practices make this the default, not the exception. If you want a claim pathway that does not leak, we can build it with you.
Ready to eliminate claim errors and accelerate collections
Let’s build a revenue cycle that gets claims paid the first time
