In ophthalmology today—particularly in subspecialties like retina and glaucoma—the gap between clinical expertise and payer policy can feel frustratingly wide. Physicians make daily decisions that can preserve vision and quality of life, only to have insurance payers challenge, delay, or deny those decisions.
As a consultant who works closely with retina practices, I’ve seen firsthand how critical it is for physicians to deliver excellent care and advocate for that care when navigating increasingly complex reimbursement systems. These same issues exist in glaucoma practices and documentation.
Advocacy does not always mean fighting back. Often, it means clearly documenting medical necessity, communicating clinical rationale so payers can understand, and being strategic about how your practice responds to coverage barriers. The physician’s voice is powerful—but only when it is clearly reflected in the medical record and backed by documentation that leaves no doubt about the appropriateness of care.
Documentation Is the Foundation of Advocacy
One of the most common reasons for denied claims is not the absence of medical justification, but rather the lack of clear documentation to support that justification. Payers can’t know the physician’s clinical intuition or experience; they see what is documented in the chart. The payers don’t “read between the lines.” Nor should they—both guessing and assuming create a slippery slope.
Strong advocacy begins long before the appeal. It starts with chart documentation explaining why a procedure, diagnostic test, or drug was selected; why alternatives aren’t suitable; and how the treatment aligns with clinical standards and the patient’s needs. The advocacy will fall flat if the documentation does not unmistakably provide the rationale for the decisions.
Vague or templated notes are insufficient in high-scrutiny areas such as retina drug management and glaucoma procedures. It is essential that the documentation is consistent across the chief complaint, examination findings, diagnostic testing, and the impression and plan. Providers must clearly connect test results to the patient’s treatment plan, demonstrating how the findings influence clinical decisions. Payers require a documented rationale for treatment—this justification must be evident in the medical record itself, not explained later through appeals or post-denial phone calls.
Advocating for Patients, One Decision at a Time
When an insurer denies a claim, delays care with excessive prior authorization requirements, or undervalues treatment by assigning a restrictively low value, the impact is real for the patient and the practice. Although payer policies may change slowly, individual decisions can still be influenced—1 patient, chart, and appeal at a time.
In retina, I often see issues arise when physicians transition patients from a lower-cost anti-VEGF agent to a more expensive one. Payers want to see evidence of poor response or complications with the first-line therapy. Simply stating that a switch was made isn’t enough. The chart should include details like persistent macular fluid on OCT or visual acuity changes. The documentation supports medical necessity and forms the foundation of any appeal.
Payer scrutiny is high when advocating for coverage of glaucoma treatments, especially newer interventions like MIGS devices or standalone sustained-release therapies. Documenting the diagnosis is no longer enough; the medical record must clearly explain why the intervention is necessary for that specific patient at that specific point in their disease course.
Physicians and staff should approach documentation with key questions in mind before moving forward with surgical authorization requests or appeals:
Topical Medication Adherence
- Has the patient shown trouble following their prescribed drop schedule?
- Is there any record of missed doses, nonadherence related to cost, physical limitations, side effects, or difficulties with the drop timing?
- Have alternative medications been attempted and recorded if adherence posed a problem?
Efficacy of Current Therapy
- Is the patient’s intraocular pressure (IOP) controlled on the current regimen?
- If not, is there clear documentation of disease progression, such as worsening visual field loss or optic nerve changes, despite medical therapy?
- Have multiple classes of drops been tried and documented with insufficient control?
Impact of Medication Burden
- Is the patient on multiple medications creating issues with tolerability, adherence, or quality of life?
- Does the chart describe ocular surface disease, allergies, or systemic side effects of chronic topical therapy?
Consideration of Other Surgical or Laser Interventions
- If SLT was considered, is there documentation explaining whether it was performed, declined, or deemed inappropriate based on clinical circumstances?
- Is the outcome documented prior to filtering surgeries (like trabeculectomy or tube shunts) being considered or performed?
Patient-Specific Factors Supporting MIGS or Sustained-Release Options
- Are cognitive or physical limitations (eg, arthritis, dementia) impacting the patient’s ability to manage topical therapy?
- Does the documentation clearly support why a procedural pharmaceutical like iDose TR (Glaukos) or a standalone MIGS procedure is appropriate and necessary based on patient-specific clinical factors?
These aren’t just checklist items for the practice or payers—they are critical for telling the full clinical story. A reviewer who doesn’t know the patient needs to understand why adding or continuing drops isn’t enough, and why a more advanced intervention is not elective but essential.
Without answering these questions in the medical record, it becomes much harder to successfully advocate for surgical authorization, device coverage, or reimbursement for newer technologies. By shifting the approach from ”What was done?” to “Why was it necessary?” practices can strengthen documentation, streamline appeals, and better protect patients’ access to innovative treatments.
Supporting the Practice and the Patient
Payer advocacy isn’t just about individual patients. It’s also about protecting the practice and the specialty. Repeated denials, underpayments, or the burden of documentation requests can strain workflows, reduce revenue, contribute to physician burnout and delay treatment leading to disease progression.
When I work with practices, I encourage them to take a proactive approach. That includes:
- Recognizing patterns in payer denials.
- Auditing documentation regularly for areas of vulnerability.
- Training physicians and staff on how to make clinical reasoning more transparent in the chart.
- Escalating coverage issues strategically when broader policy change is needed.
- Collaborating with peers and participating in national and local professional societies, which can help amplify the provider’s voice and strengthen their advocacy efforts.
- Providing high-quality care is not enough; we must demonstrate, explain, and sometimes defend it.
Final Thoughts: Amplifying the Physician’s Voice
The physician’s voice is uniquely powerful, but only if it’s captured in a way payers can process. As a consultant, I’m not here to change your clinical decision-making. I’m here to help ensure your decisions are communicated effectively, documented thoroughly, and reimbursed appropriately.
Whether it’s a high-cost injection or a MIGS device, the strongest cases begin with a clear record that tells the payer, “Here’s why this matters.” When the chart speaks clearly, the physician’s voice is amplified—and that’s when advocacy truly works. GP
