AAO 2025 Recap: Reimbursement Trends and Industry Insights

Recorded live at American Academy of Ophthalmology in Orlando, Rebecca Greenlaw and Mary Pat Johnson share highlights from the meeting — from exciting new technology to pressing payer issues like Humana denials and downcoding. Hear the latest on reimbursement trends, fee schedule updates, and what to expect heading into 2026.

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Transcript

Welcome to Ophthalmology Reimbursed, the podcast that discusses all things coding, reimbursement, auditing, and education for the ophthalmic community. Hey, it's Rebecca Greenlaw. Hi, it's Mary Pat Johnson.

We're here at AAO wrapping up in our final day. It's been a few busy days. It really has.

Exciting stuff happening in ophthalmology, but it has been busy. It's great seeing clients and meeting up with people. It really was.

Thanks everyone who took the time to meet with us. If we missed you and you still have questions, don't hesitate to reach out when you get back to your office. We'd love to hear from you.

We wanted to just take a few minutes to share with you some of the things we heard and heard about at the meeting. Certainly a lot happening in industry, new lenses, new surgical equipment. Like I said, an exciting time.

But at the same time, we did hear a few comments from clients, couple from other consultants about changes in reimbursement that we thought you might be interested in. So Humana. Humana is our nightmare.

Humana. All right. Well, Humana is denying with reason code CO2 36 when billing an office visit and testing together.

Denials are coming in for the office visits. This is a wildfire. So much so that AAO has gotten involved.

They've reached out to Humana, let them know that there is a problem with their edits. Has implored Humana to take a look. Humana is supposed to be reaching back out to AAO once they have a resolution.

And I've not seen or heard of that resolution yet. Yeah. Same.

I did hear a couple other payers have gotten involved as well. Yeah. So Cigna, Molina.

I did hear some with Blue Cross Blue Shield. So just be aware this is, this is an issue. It's a very big issue.

It is being addressed about the only thing that you can do right now is dispute it on the availability portal for Humana and keep track, keep track of the, of the denials. Yeah. Hopefully once it's resolved, you'll get an opportunity to rebuild if they don't automatically reprocess.

So this is kind of on the heels of Humana doing the down coding in the last several months. That too has kind of gotten out of control. It really has.

And I'm, I'm torn as to why this is happening. Cause I, I'm hearing that the codes are coming back different on the EOB than what was submitted on the claim. And my only suspicion is, does the diagnosis code match? So if you build a level four, for example, and as your primary diagnosis, you put something that sounded to Humana to not need that level of care.

I'm curious if that's the reason they're down coding. But again, since they're not asking for charts, we don't really know a reason code. Right.

They're not reviewing charts. They're just down coding. I've not heard a resolution on this yet.

And I've not heard any involvement from the Academy on this. And I'd get, I'd say, I'd love to get a resolution, but I think all you can do is appeal. Can I apologize guys? That's kind of tedious.

Next, I have lots of questions about the government shutdown. Everyone's worried about what's happening to claims and when we'll be paid. But I think you did see something on this recently, right? Yeah.

So CMS is saying that there's not going to be any delays in reimbursements, which is good except for claims that are being submitted for expired provisions. Telehealth. Right.

So those claims would have been denied whether the government shut down or not. Right. That's a separate issue entirely.

Yep. Yeah. And then along the same lines as fees and Medicare, we did recently see right when we landed in Orlando a few days back, providing some different information for the proposed fee schedule, where it had two different conversion factors listed.

One for providers and practices that were part of APMs and one for those that were not. That has not yet been finalized. So stay tuned.

The fee schedule information, once it's published, will certainly bring to you a summary of the updates that affect ophthalmology. Yeah. So great topic for what's new for 2026.

Yeah. Certainly part of that webinar. Yep.

Which that's going to be rolling out first part of December. Get registered. Lots of news.

Lots of news. Thanks again for those of you who took time to meet with us at the meeting. Everyone stay well.

Thanks for listening to Ophthalmology Reimbursed brought to you by Corcoran Consulting Group, the experts in coding, reimbursement, auditing, and education for the ophthalmic community. To learn more about how we can support your practice, visit corcoranccg.com. Be sure to follow and leave a review wherever you listen to podcasts. Until next time, thanks for listening to Ophthalmology Reimbursed.