Being an Open Access provider

3 ways to submit out-of-network vision claims

How do eye care providers handle out-of-network claims? We take a look at three different approaches to out-of-network claim submission.
Published 6.22.2021

Out-of-network claims can be confusing and there’s a reason for that: Vision plans want members seeing their in-network providers.

As a result, out-of-network claims can prove troublesome for patients and providers alike if they don’t know how to submit correctly. Submitting claims this way can be more difficult than doing so in-network. And no one wants to deal with the phone calls, negotiations and appeals that can follow a rejected claim.

However, sometimes you have no choice but to submit them. Or maybe you’ve found that without vision plans you’re enjoying network freedom and you're able to offer patients better quality care. Whether it’s a one-off situation or you’ve decided to be an out-of-network provider, it’s important that you’re submitting these claims correctly.

Let’s take a look at three ways that out-of-network vision claims are submitted:

The provider submits an out-of-network claim form

Out-of-network care can have a stigma. That’s true for patients and providers alike. On the provider end, one reason for this is paper claim form submissions.

Some vision plans don’t have clearinghouses for out-of-network claim submissions. As a result, out-of-network providers can’t access the same helpful portals that those vision plans offer for in-network claim submission. This makes verifying vision benefits and submitting claims much more difficult. That’s why some providers end up putting the onus on the patients. At least patients sometimes have access to the tools that make out-of-network claim submission easier.

However, that’s not great for patient experience. For that reason, some out-of-network providers submit claims for their patients. Without access to a provider portal this will likely require that you complete and send paper CMS-1500 forms to the vision plans.

If your in-house billing team is filling out these forms for patients it is essential they make sure they get the information right. Claim rejection appeals can be costly in terms of time invested. And they worsen patient experience. Additionally, they should make sure they’re filing claims in a timely manner. Claims sent outside of a certain window may be denied.

The patient submits the out-of-network claim

If the cost of retaining an in-house- or third-party billing team is too high, you can ask patients to submit their out-of-network claims.

This isn’t the ideal experience, but it takes pressure off of your office. Additionally, patients are more likely to have access to online out-of-network claim submission if it is available. That makes it an appealing option for providers who drop vision plans.

If you go this route it’s important to offer patient education to ensure that their claims are correctly submitted. Repeated claim rejections may drive your patients to find another provider. Go over the out-of-network claims submission process with each patient to help them make sure they’re not struggling on the phone with their vision plan later on.

Similarly, if patients are required to submit CMS-1500 paper forms, make sure you help them obtain the form for their claims.

Which option for out-of-network claim submission offers the best patient experience?
Which option for out-of-network claim submission offers the best patient experience?

The provider submits the out-of-network claim using Anagram

There’s a third option for out-of-network claims submissions that’s more affordable than retaining a billing team, that offers a better experience than asking patients to submit themselves and that mitigates the risk of claim rejections.

Anagram is an out-of-network billing platform that solves the problems with the other two methods for out-of-network claim submissions.

Submitting out-of-network claims this way is fast and easy. The provider logs into Anagram’s online application, fills out the patient information, adds the exam and material codes, and clicks submit. After that, the patient can expect reimbursement in a few weeks. Additionally, the platform reduces claim rejection risk by verifying patient information before the provider is allowed to click submit.

And by making it easy for providers to submit out-of-network claims for their patients, Anagram takes claim submission out of the patients’ hands and helps providers offer high-quality experiences.

Which out-of-network claim submission works best for you?

Submitting claims for patients; asking them to send the claims; using Anagram: Which works best for you?

You have to make the decision that’s right for your practice’s unique needs. Needs that encompass those of your patients, your staff and, of course, yourself. If you’re seeing very few out-of-network patients, then it probably makes sense to just have your staff take the time to submit the claim. However, if you regularly see patients on an out-of-network basis then Anagram may represent the better choice.

Connor McGann
Connor McGann, Content Marketing Manager
Connor McGann is Anagram's content marketing manager. He joined Anagram in February 2020. Previously he was a finance writer and animation project manager at a marketing agency, and managed content for a live chat provider that serviced various industries including health care and plastic surgery.

Related Articles