Eye Care revenue cycle management

Eye-care revenue concentrates in expensive injectables and the medical-vs-vision split. AI agents assemble anti-VEGF authorizations, reconcile buy-and-bill down to the wasted unit, route every claim to the right payer, and work the rest of the cycle.

The money in eye care rides on high-cost injectable drugs and a benefit split that trips up the front desk. Anti-VEGF PAs, J-code units and drug wastage are unforgiving, and sending a claim to the wrong plan means a write-off. MedXFlow's agents handle the parts that leak the most - and everything downstream.

Injectable drug authorization & buy-and-bill

  • Anti-VEGF prior authorization - Assembles PA packets for Eylea, Lucentis, Avastin and Vabysmo - diagnosis, prior therapy and imaging - and tracks renewals.
  • J-code units & wastage - Reconciles drug units drawn vs. documented vs. billed, with JW/JZ wastage-modifier validation on single-use vials.
  • Buy-and-bill reconciliation - Matches drug purchases to administered doses and payments, so nothing bought goes unbilled.
  • Drug inventory & lot/expiry tracking - Tracks vials by lot and expiry to prevent waste and stockouts.
  • Copay-assistance enrollment - Enrolls patients in manufacturer copay and assistance programs.

Medical vs. vision benefit determination

  • Route to the right plan - Determines medical vs. routine-vision coverage before the visit and sends the claim to the correct payer.
  • Dual-benefit verification - Verifies both medical and vision benefits, copays and frequency limits.
  • Vision-plan eligibility & authorization - Checks VSP/EyeMed eligibility and materials authorizations.

Coding & compliance

  • Retina & imaging coding - Codes OCT, fundus photography and visual fields, respecting payer frequency limits.
  • Eye codes vs. E/M - Chooses correctly between Eye codes (920xx) and E/M (992xx).
  • Bilateral & modifier accuracy - Applies RT/LT/50 and other modifiers correctly.
  • Post-cataract global tracking - Tracks the surgical global period so post-op visits bill correctly.

Prior authorization (procedures)

  • Cataract, YAG, laser & oculoplastics PA - Assembles authorizations and medical-necessity documentation for procedures.
  • Medical-necessity matching - Matches the encounter to payer coverage criteria.

Claims & submission

  • Claim scrubbing & NCCI edits - Scrubs claims against bundling and payer edits.
  • Claim status follow-up - Polls status and chases stuck claims.

Payments, denials & AR

  • ERA auto-posting - Posts remittances and adjustments automatically.
  • Drug & imaging denial recovery - Auto-appeals anti-VEGF and imaging-frequency denials.
  • Underpayment detection - Flags J-code payments below contracted or ASP-based rates.

Patient collections

  • Refraction & non-covered collection - Collects refraction and other non-covered fees at the desk.
  • Statements & payment plans - Sends statements and offers payment plans.

Front office & scheduling

  • Recall for chronic care - Recalls glaucoma, diabetic-eye and injection-series patients on schedule.
  • Call answering & scheduling - Answers calls and schedules clinic visits, imaging and injections.

Analytics

  • Drug-margin & denial dashboards - Dashboards drug margin, wastage and denial trends.

What you get

  • Never leave a bought anti-VEGF dose unbilled
  • Document drug wastage (JW/JZ) on every single-use vial
  • Send each claim to the right payer - medical or vision
  • Respect imaging frequency limits to avoid denials
  • Choose Eye codes vs. E/M correctly
  • Recover anti-VEGF and imaging denials fast

Frequently asked questions

What is the difference between medical and vision benefits?

A vision plan covers routine refractive care - eye exams, glasses and contacts. Medical insurance covers diagnosis and treatment of eye disease such as glaucoma, cataracts or macular degeneration. Billing the wrong plan is a common write-off, so the determination must be made before the visit.

How are anti-VEGF injections billed?

The drug is billed by J-code in the correct number of units, alongside the injection procedure. Because these drugs are expensive and usually require prior authorization, both the authorization and the unit count have to be right or the practice absorbs a large loss.

What are the JW and JZ modifiers?

JW reports drug discarded from a single-use vial, and JZ attests that there was no wastage. For high-cost injectables, documenting wastage correctly is how the practice is reimbursed for the full vial rather than only the administered dose.

What is buy-and-bill in ophthalmology?

The practice purchases the drug, administers it, then bills the payer for it. It ties up capital and carries real risk, so reconciling every vial purchased against units billed - including wastage - is essential to avoid losses.