How to Be Ophthalmic Claims Processor - Job Description, Skills, and Interview Questions

Mar 27, 2020 / 6 Minutes Read / By Albert

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The lack of an efficient ophthalmic claims processor can have a significant effect on a patient's care. Claims processing delays can lead to longer wait times for appointments and treatment, resulting in delays in obtaining the necessary care. In addition, if an incorrect diagnosis or treatment is made due to a delay in claim processing, it can lead to a misdiagnosis or increased healthcare costs.

To prevent this from happening, it is important for healthcare providers to have access to a reliable and accurate ophthalmic claims processor, one that is able to process claims quickly and accurately. This will help to ensure that patients receive the necessary care and treatment in a timely manner, ultimately providing them with improved health outcomes.

Steps How to Become

Obtain a high school diploma or equivalent. Most employers look for applicants who have at least a high school degree or equivalent.
Consider obtaining a college degree or certificate in medical billing and coding. Some employers prefer applicants who have a college degree or certification in medical billing and coding.
Obtain on-the-job training. Some employers offer on-the-job training for Ophthalmic Claims Processors, but others may require that you have prior experience in the field.
Gather experience in the medical field. Some employers require that applicants have prior experience in the medical field, such as working as a medical assistant, medical receptionist, or medical coder.
Become familiar with the coding system used by ophthalmologists. Many ophthalmologists use a specialized coding system to bill for services provided. Becoming familiar with this system is important for an Ophthalmic Claims Processor.
Familiarize yourself with applicable laws and regulations. Ophthalmic Claims Processors must be familiar with relevant laws and regulations in order to process claims accurately.
Obtain certification as an Ophthalmic Claims Processor. Certification is not required in all states, but it can be beneficial when seeking employment in the field.

The ability to process ophthalmic claims efficiently and effectively requires a strong attention to detail, as well as a comprehensive understanding of the various regulations and policies associated with ophthalmic care. Improperly processed claims can result in costly delays in payments, which can have a devastating effect on both the patient and the provider. To avoid this, an ophthalmic claims processor must be familiar with all relevant coding and billing systems, have a thorough understanding of insurance protocols, and possess excellent organizational skills.

Furthermore, they must have the ability to accurately interpret complex medical terminology, and be able to quickly identify errors or discrepancies in patient information. With a combination of these skills, an ophthalmic claims processor can ensure that all claims are processed accurately and efficiently, resulting in fewer delays and smoother payments for both patient and provider.

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Job Description

Monitor and process ophthalmic claims according to established policies and procedures.
Verify accuracy of patient demographic and insurance information.
Resolve complex billing issues with payers, providers, and patients.
Provide timely feedback to providers and staff regarding claims status.
Maintain up-to-date knowledge of ophthalmic billing rules and regulations.
Handle incoming calls from patients, providers, and payers regarding claims.
Ensure accurate processing of claims by reviewing all claims prior to submission to payers.
Monitor and review all claim denials, rejections, underpayments, and appeals.
Research and provide responses to inquiries from payers, providers, and patients.
Identify areas of improvement in the workflow process and recommend solutions.

Skills and Competencies to Have

Knowledge of health insurance policies, procedures, and regulations
Ability to interpret and explain vision insurance policies and benefits
Familiarity with coding systems such as ICD-10, HCPCS, CPT, and other ophthalmic coding systems
Excellent organizational and time-management skills
Ability to accurately enter data into computer systems
Excellent customer service skills and the ability to effectively communicate with patients and insurance companies
Ability to multi-task and prioritize work
Knowledge of Medical Terminology
Knowledge of Microsoft Office programs, such as Word and Excel
Ability to solve problems quickly and effectively

The ability to process ophthalmic claims quickly and accurately is a crucial skill for any ophthalmic claims processor. Good organizational skills, attention to detail, and strong problem-solving abilities are key in order to ensure that all claims are handled correctly and in a timely manner. In addition, the ability to understand medical terminology and the various codes used to process claims can help a processor identify and quickly resolve any issues that may arise.

Good communication skills are also essential for any ophthalmic claims processor as they must be able to interact with doctors, patients, and insurance companies in order to obtain necessary information and resolve problems in a timely manner. Ophthalmic claims processors who possess these skills will be better equipped to handle the complexities of the job and help ensure that all claims are processed correctly and efficiently.

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Frequent Interview Questions

What experience do you have with ophthalmic claims processing?
How do you ensure accuracy when processing ophthalmic claims?
What strategies do you use to stay organized and efficient when processing claims?
How do you handle complex or difficult claims?
What challenges have you faced when processing ophthalmic claims?
How do you stay up to date with changes in the insurance industry?
Describe a time when you provided exceptional customer service in response to a challenging claim.
What tools do you use to manage large volumes of claims?
What is your experience with coding and billing related to ophthalmic claims?
How do you handle conflicting information between providers and insurers?

Common Tools in Industry

Claim Management Software. Software used to manage and process insurance claims from start to finish, including tracking, billing, and payment. (Example: HealthClaims360)
Medical Billing Software. Software used to generate accurate medical bills for insurance companies and patients. (Example: Medisoft)
Medical Coding Software. Software used to accurately code medical diagnoses, procedures, and services for reimbursement purposes. (Example: ICD-10 Coder)
Document Management Software. Software used to store, manage, and organize all types of documents. (Example: Office 365)
Electronic Medical Records (EMR) Software. Software used to store patient information electronically and make it available across multiple health care providers. (Example: Cerner)
Optical Character Recognition (OCR) Software. Software used to recognize text and characters from scanned documents and images. (Example: Abbyy FineReader)

Professional Organizations to Know

American Academy of Ophthalmology (AAO)
American Society of Cataract and Refractive Surgery (ASCRS)
American Glaucoma Society (AGS)
American Society of Retina Specialists (ASRS)
Contact Lens Association of Ophthalmologists (CLAO)
Association of Regulatory Boards of Optometry (ARBO)
National Association of Vision Care Plans (NAVCP)
National Board of Examiners in Optometry (NBEO)
National Council of Optometric Practitioners (NCOP)
American Optometric Association (AOA)

We also have Ophthalmic Clinical Research Associate, Ophthalmic Medical Biller and Coder, and Ophthalmic Claims Examiner jobs reports.

Common Important Terms

CPT Codes. CPT (Current Procedural Terminology) codes are five-digit codes used to identify medical services and procedures.
ICD-10 Codes. ICD-10 (International Classification of Diseases) codes are used to classify medical diagnoses and procedures.
UB04 Form. The UB04 form is the standard bill form used by healthcare providers to submit claims for reimbursement from insurance companies.
EOBs. Explanation of Benefits (EOB) documents are sent out by insurance companies to explain the amount they will pay for a claim.
HIPAA. The Health Insurance Portability and Accountability Act (HIPAA) is a federal law that protects the privacy of patient health information.
Reimbursement. Reimbursement is the process of providing payment to healthcare providers for services rendered.
Deductible. A deductible is the amount of money that an insured has to pay out-of-pocket before the insurance company will start covering costs.
Co-Insurance. Co-insurance is a form of cost sharing between an insured and their insurer, typically in the form of a percentage split for medical costs.
Preauthorization. Preauthorization is a process that requires physicians to get approval from an insurance company before providing a service or treatment.
Provider Network. A provider network is a list of healthcare providers who have contracted with an insurance company to provide services to plan members at a discounted rate.

Frequently Asked Questions

What is an Ophthalmic Claims Processor?

An Ophthalmic Claims Processor is a trained medical professional responsible for reviewing, processing and verifying insurance claims related to ophthalmology services.

What qualifications are required to become an Ophthalmic Claims Processor?

To become an Ophthalmic Claims Processor, candidates must possess a high school diploma or GED, have an understanding of medical terminology, be familiar with medical coding and billing processes, and have a working knowledge of health insurance plans.

What are the duties of an Ophthalmic Claims Processor?

The primary duties of an Ophthalmic Claims Processor include verifying patient information, reviewing and entering claims data into a computer system, and ensuring accurate coding of ophthalmology services. Additional duties may include addressing billing inquiries, resolving discrepancies between charges and payments, and responding to patient requests.

How long does it take to process an ophthalmology claim?

The length of time it takes to process an ophthalmology claim varies depending on the complexity of the claim and the insurer. Generally, it may take anywhere from two days to two weeks to process a claim.