Anti-VEGF denials are recoverable. Most never get worked.
Intravitreal injections, retinal imaging modifiers, and buy-and-bill workflows carry some of the highest denial rates in all of specialty medicine. Ember audits every encounter, appeals every denial, and surfaces underpayments your team cannot find manually.
Trusted by specialty groups and health systems
Where ophthalmology revenue leaks
Top ophthalmology denials Ember resolves
Ember addresses the recurring benefit, authorization, coding, and frequency-limit issues that delay or reduce payment for ophthalmology care.
01 · Benefit routing
Claims deny when medical care is routed to a vision benefit, or the wrong plan is billed.
Ophthalmology visits often cross medical and vision benefits. Ember helps route each service to the appropriate benefit and payer before submission, reducing avoidable wrong-plan denials.
Medical vs. vision benefit routing02 · Prior authorization
Retinal treatments and IOL-related services are denied when authorization is missing or incomplete.
Drug injection and ASC billing bring separate authorization and documentation requirements. Ember helps teams identify what is required for retinal care and IOL-related services before the claim is submitted.
Retinal care · IOL · Drug injection · ASC03 · Downcoding and E/M reductions
Exam levels are reduced when documentation and payer rules do not align.
Medicare Advantage plans may downcode exam levels, while diagnostic services are also subject to frequency limitations. Ember reviews the documented visit level and testing history so teams can prevent or challenge inappropriate reductions.
MA exam levels · Diagnostic frequency limitsThree engines.
One source of truth.
Ember connects clinical documentation, payer policy, and contract terms into a single intelligence layer that sits on top of your EHR. Built for the complexity ophthalmology billing actually requires.
01 · Foundation
Data Engine
Unifies clinical documentation, coding decisions, payer policy, and contracts across every encounter and provider. Ingests directly from ModMed, Nextech, Epic, and every major ophthalmology EHR.
M. Tanaka
Encounter #O-40192
02 · Audit
Coding Engine
Reviews 100% of encounters against national standards, payer-specific policies, your internal guidelines, and your payer contracts. Every anti-VEGF claim, every injection modifier, every imaging code, validated before submission.
Append modifier RT — right eye
CMS NCCI PTP · confidence 0.96
03 · Recovery
Appeal Engine
Reads CARC and RARC codes, identifies the applicable LCD/NCD policy and contract terms, drafts the appeal with clinical documentation, and tracks every claim to adjudication.
Re: Claim #O-40192 · Denial CO-197
The denied anti-VEGF injection meets step-therapy criteria under LCD L34760 and is reimbursable per contract §3.1…
Audit upstream.
Appeal downstream.
Two workflows do most of the work for ophthalmology practices. The first prevents denials before they happen. The second recovers the ones that slip through.
Pre-bill audit
Catch the anti-VEGF issue before the claim leaves.
Ember reviews every encounter against coding standards, payer policy, and your contracts. Anti-VEGF documentation, modifier combinations, and imaging codes are flagged before submission.
- 1
Ingest the encounter
Pulls clinical notes, codes, and modifiers from ModMed, Nextech, Epic, and your practice management system.
- 2
Validate against rules
Checks CPT, HCPCS, modifiers, and documentation completeness against payer policy and your contracts. Flags anti-VEGF step therapy gaps, auth mismatches, and modifier errors.
- 3
Recommend with citation
Returns the suggested correction tied to the exact rule, payer policy, or LCD/NCD reference, no guessing, no callbacks to the payer.
- 4
Educate the provider
Coding patterns drive provider-level coaching, so injection documentation and modifier accuracy improve across every site.
Append modifier RT — right eye
CMS NCCI PTP · confidence 0.97
+23%
Clean-claim rate
100%
Encounters reviewed
+5%
Net collection rate
Automated appeals
Pull. Review. Push.
When a denial occurs, Ember identifies the root cause, retrieves injection and imaging records, references payer policy and contract terms, drafts the appeal, and tracks it through adjudication.
Auth not on file
Missing modifier
Step therapy
Dx mismatch
Anti-VEGF appeal
-57%
Denial rate
-45%
Cost to collect
+9.3%
Net revenue per appt
The full revenue cycle
From eligibility to adjudication. Covered.
Audit and appeals are the workhorses, but Ember protects ophthalmology revenue at every stage of the cycle.
Eligibility Verification
Confirms active coverage and vision vs. medical benefit designation before the visit, and flags anti-VEGF coverage gaps before they become billing problems.
Prior Authorization
Checks auth requirements in real time for anti-VEGF injections, generates clinical documentation, and submits to payer portals automatically. Tracks every active auth to expiration.
AI Medical Coding
Reviews 100% of encounters, injection codes, imaging modifiers, and E/M levels, against national standards and payer rules before claims submit.
Pre-bill Audit
Predicts and prevents denials before claims go out, catching anti-VEGF documentation gaps, modifier errors, and auth mismatches before they generate write-offs.
Denial Management
Full appeal lifecycle for every denial type, step therapy, auth failure, modifier edit, and imaging bundling, with automated drafts tracked to adjudication.
Underpayment Recovery
Parses contracts to model what each injection claim should pay, then surfaces line-item underpayments on buy-and-bill at scale.
High-value retina revenue, recovered
$1.5M
revenue identified
8.1x
first-quarter ROI
41%
fewer preventable denials
152k
encounters reviewed
Based on Ember AI benchmarks across customer practices. Results vary by payer mix and specialty.
Frequently asked questions
Everything you need to know about how Ember fits into your revenue cycle.
- 65% less manual effort, as reported by customers
- Faster cash acceleration
- Prevent 55%+ of denials
We provide ROI benchmarks and dashboards so you can track outcomes from day one.
See what your ophthalmology practice is leaving on the table
Bring us 30 days of denial data. We'll show you exactly where the revenue is and how Ember would recover it.