AgentAI for Ophthalmology
Ophthalmology billing that bundles clean.
Medical-vs-vision benefit confusion, diagnostic-test bundling, retina-injection drug units, modifier-25 discipline — the eye-care billing company we acquired wrote the book on all of it. Now agents run it 24/7, by provider, payer, location, and subspecialty.
We’ve seen your denials before
Eye care doesn’t leak like other specialties. It leaks in benefit frames, bundling edits, and drug units.
Measured across the ophthalmology practices we bill — 90 days of real payer responses, spring 2026. These are the denials our agents are built to prevent:
Medical vs vision benefit
The same exam belongs to the medical plan or the vision plan depending on the diagnosis. Billed to the wrong one, it’s denied as non-covered — even though it was covered elsewhere.
Benefit frame matched to the diagnosis before submission.
Diagnostic-test bundling
92133/92134 OCT billed with bilateral errors, visual fields denied on frequency, and the 92014 vs 99214 exam-code choice quietly leaving money on every visit.
Bundling and frequency rules checked per eye, per payer.
Retina injections & drug units
High-cost retina drugs under-billed against the invoice, and JW/JZ discarded-drug amounts claimed outside the narrow Medicare context that allows them.
Units matched to invoice; JW/JZ reviewed by certified coders.
Modifier 25 with injections
HHS OIG found 22 of 24 sampled E/M services billed the same day as eye injections lacked support for modifier 25. Miss it and the visit is denied; force it and you’re a repayment risk.
Agents flag and surface the evidence — certified coders decide.
Surgery & global periods
Cataract co-management (66984-54/55) and global-period exceptions billed without the right modifier discipline — the split claim denied, or double-paid and clawed back.
Co-management and global rules applied on every surgical claim.
Payer response & follow-up
Payer record requests unanswered until deadlines pass, and high-dollar claims sitting with no response — aging quietly toward the timely-filing deadline.
Every request and every silent claim owned to an outcome.
What we handle
Where we’ve acquired elite billing companies, their veteran billers oversee the agents — and the agents learn your specialty from millions of real paid claims. Diagnostic-test bundling, global-period rules, and retinal injection J-codes kept clean.
See what you’d keepThe rule library
Eye-care rules, applied by agents — governed by certified coders.
What the acquired eye-care team brought onto the platform:
Every rule carries its source and effective date. Payer and jurisdiction noted where relevant; superseded guidance stays distinguishable; every correction records the human decision behind it.
Measured on ophthalmology claims
The platform numbers, with cohorts attached.
Who runs it
The eye-care billing company we acquired works only in ophthalmology and optometry — certified ophthalmic billing and coding specialists whose judgment trains and supervises our agents.
Eye care lives on the line between covered and non-covered — benefit frames, bundling edits, drug units, and modifier discipline. Agents run the checks around the clock; certified eye-care coders make the judgment calls, with the evidence attached.
Eye-care expertise, immediately
Eye-care judgment behind the agents.
Not a call center. The eye-care specialists who joined AgentAI work only in ophthalmology and optometry — the agents just took the busywork off their desks.
Built and scaled an eye-care billing company to 100+ clients before bringing it to AgentAI. Thirty-plus years of combined team experience across ophthalmology and optometry reimbursement — retina injections, diagnostics, surgical and office billing alike.
The certified eye-care coders who review every coding-sensitive recommendation the agents surface — modifier-25 calls, retina drug units, co-management splits, and diagnostic-test bundling. Agents flag; these people decide.
Questions ophthalmology practices ask
Do we need to replace our EHR, PM, or clearinghouse?
No. We connect to what you already use and work as an extension of it — the scan itself is read-only under a signed BAA. System and clearinghouse continuity is confirmed during scoping for your specific setup.
Can the scan start with one provider, location, or subspecialty?
Yes — retina-only, a single site, or a single payer. That’s exactly how the 5-step path works: scoped cohort, review, pilot in parallel, then controlled expansion.
Who reviews coding-sensitive recommendations?
The certified ophthalmic coding specialists on our team. Agents flag and surface the evidence; people decide — especially modifier 25 and retina drug cases, where OIG scrutiny lives.
How do you handle retina injections, drug units, and JW/JZ?
Units are matched to the buy-and-bill invoice on every line. JW/JZ discarded-drug amounts are claimed only in the specific Medicare context CMS allows, with the product, container, dose, and payer rule documented per case — and a certified coder reviewing.
How do you distinguish medical and vision-benefit workflows?
Every encounter is matched to the right benefit frame from the diagnosis before submission — so a covered medical exam never dies as a non-covered vision claim, and vice versa.
What do you do about payers downcoding our visits?
Downcoding is now routine — our specialty billing leadership sees roughly three in four payers reducing levels, most often a level 4 office visit paid as a level 3. Downcoded lines are flagged rather than written off: the record supporting the billed level is assembled and the claim is appealed with the notes attached. Recovery depends on the documentation and the payer’s rule; nothing here guarantees payment.
How do we know we are being paid our contracted rate?
Every payment is checked line by line against the fee schedule in your provider contract, not against a national average. Underpayments and silent fee-schedule changes surface as a worklist showing expected amount, paid amount, and the difference per claim — so they can be appealed or renegotiated instead of quietly absorbed.
What reporting do we get, and can we compare ourselves to peers?
Readable dashboards on the KPIs that decide a practice’s cash: days in A/R, clean-claim rate, denial rate and reasons, net collection rate, and payment velocity — broken out per provider, location, and payer. Where our books carry enough comparable ophthalmology volume, we show how your numbers sit against that peer cohort rather than against a national benchmark.
Who do we actually talk to when something goes wrong?
A named account team you reach directly — no ticket queue, no phone tree, and no escalation handed back to your front-desk staff to chase. The same specialty billers who work your claims are the people who answer, which is why they can answer without reading from a script.
See what your ophthalmology billing is leaking.
Free 90-day Ophthalmology Revenue Leak Scan — read-only, in plain English. Your own benefit frames, bundling edits, drug units, and aged no-response, with dollars attached.
Run a Free Revenue Leak ScanSources: coding practices reflect the eye-care billing company we acquired and rules its certified specialists apply. Modifier-25 finding: HHS OIG 2025 review of same-day E/M with eye injections. Leadership titles shown as publicly listed. Stats: measured on live platform books (podiatry cohorts, labeled per stat); your ophthalmology cohort comes with the Leak Scan. The downcoding prevalence figure reflects our specialty billing leadership’s observation across the books we operate, not a published study. Peer comparison is offered only where our books hold enough comparable volume in your specialty. Not a guarantee of your results.