The eye care industry – from solo ophthalmologists and optometrists to large eye surgery centers – faces unique complexities in provider and facility credentialing and revenue cycle management (RCM). Without a strategic approach, these challenges can impact patient access, cash flow, and compliance.

In this blog, we explore common pitfalls in credentialing and billing for eye care organizations and practical ways to overcome them.

The Credentialing Maze: A Significant Hurdle

Common Credentialing Challenges

• Medicare Certification Delays for Eye Surgery Centers (ASCs)
  Obtaining initial ASC Medicare certification can take 4 to 9 months and involves compliance with CMS Conditions for Coverage (42 CFR Part 416). Without this certification, surgery centers cannot bill Medicare or even some commercial payers. Many eye centers underestimate the preparation required.
• Dual Credentialing for MDs and ODs
  Ophthalmology practices often employ both ophthalmologists (MD/DO) and optometrists (OD). Credentialing rules and payer participation policies differ for each provider type, adding complexity.
• Vision vs. Medical Payer Credentialing
  Vision plans (VSP, EyeMed, Davis Vision, etc.) require separate credentialing workflows from medical payers (Medicare, BCBS, UHC, Aetna). Many practices struggle to manage both tracks effectively.
• Facility Licensing and State Requirements
  ASCs must meet state-specific licensing and accreditation requirements (e.g. Joint Commission, AAAHC, AAAASF), in addition to Medicare’s Conditions for Coverage – a regulatory puzzle that can delay certification.
• Recredentialing Lapses
  Busy eye care organizations sometimes miss recredentialing deadlines or fail to update CAQH profiles, causing claim denials or loss of in-network status.

Billing Complexities in Eye Care

Revenue Cycle Pain Points

• Bundling & Modifiers for Eye Surgeries
  Billing for eye procedures (e.g., cataract surgery, retinal repairs) requires correct use of modifiers (e.g., RT, LT, 50, 59, 25) and navigating payer-specific bundling edits.
• Anesthesia Billing Coordination
  If a separate anesthesia provider is involved, clear billing coordination is required to avoid duplicate billing or denials.
• Vision vs. Medical Claim Routing
  Determining whether to bill a vision plan vs. a medical payer is nuanced – especially when medical eye conditions are treated in the same visit as a refractive or routine eye exam.
• ASC Technical Component Billing
  Eye ASCs must correctly bill facility fees for Medicare-approved CPT codes while providers bill the professional component.When services are performed in an Eye ASC, the physicians and other healthcare providers involved may bill separately for their professional services. However, the payment rate for the professional services is adjusted to account for the fact that the ASC is incurring the facility costs.
  
  Modifier Usage:
  • ASCs – Bill the technical (facility) component of services using modifier TC, when a service has both technical and professional components. ASCs also bill any covered ancillary services with modifier TC.
  • Physicians and Other Professionals – Bill the professional component of services using modifier 26. This ensures that payments are appropriately split between the professional and facility components when services are rendered in an ASC setting.
• Coverage Rules for Premium IOLs
  Premium intraocular lenses (IOLs) and refractive upgrades often involve patient financial responsibility. Practices must implement clear advance beneficiary notice (ABN) and patient collection processes.

Proven Solutions for Success

Streamlining Credentialing

Engage an experienced provider credentialing company or partner who understands:

• ASC Medicare certification
• Multi-provider (MD, OD, CRNA) credentialing
• Facility and vision plan credentialing requirements
• Payer enrollment timelines and CAQH management

Use a credentialing portals like CAQH, to track expirables and recredentialing cycles.

Integrate credentialing workflows with billing and payer enrollment processes to ensure readiness for revenue cycle.

Optimizing Billing Workflows

Work with a specialized eye care billing team that knows:

• Modifier usage for eye surgeries
• Vision vs. medical plan billing decision trees
• ASC technical and professional billing rules
• Local coverage determinations (LCDs) for ophthalmology procedures

Implement denial prevention programs focusing on:

• Prior authorization tracking
• Eligibility verification
• Timely filing management
• Recredentialing monitoring

Provide staff training on ABN use and patient financial counseling for premium IOLs and refractive upgrades.

Conclusion

Credentialing and billing for ophthalmologists, optometrists, and eye surgery centers are inherently complex – and mistakes can cause revenue delays, compliance risks, and patient dissatisfaction.

By partnering with an expert provider credentialing and medical billing services company like TriumpHealth who understands the nuances of the eye care industry, our organization can:

• Accelerate payer enrollment
• Minimize claim denials
• Maximize revenue
• Ensure compliance

Ready to streamline your credentialing and revenue cycle process? Schedule a consultation today or contact us at [email protected] or (888) 747-3836 x0, to learn how our credentialing and revenue cycle experts can help your eye care practice or eye surgery center thrive.