Skip to the main content.
Request Demo

3 min read

Why Do So Many Retina Specialists Use the CareMetx Medical Benefit Verification?

Why Do So Many Retina Specialists Use the CareMetx Medical Benefit Verification?

The demand for specialized treatment of retinal conditions, including age-related macular degeneration (AMD), diabetic retinopathy, and retinal vascular disorders, is increasing.  

Although these treatments can be transformative, beginning retinal therapy for a newly diagnosed patient can be a complex process. Nevertheless, retina specialists who work with us share that the reliable CareMetx medical benefit verification transforms the initiation process—giving them confidence that patients can begin treatment in a timely way. 

Tackling the Nuances of Retina Therapy Initiation 

To keep up with rising demand for retina therapy, most practices want to institute an efficient initiation process that streamlines the treatment, thus —enabling high throughput—while simplifying the patient journey.  

Once a patient is diagnosed with a retinal condition, a critical first step is to confirm their insurance benefits. This includes determining whether the treatment will be covered, whether prior authorization is needed, and tallying the patient’s out-of-pocket expense. Until those details are confirmed, the provider may be reluctant to schedule the first treatment, because they prefer not to tie up an appointment slot for a patient whose treatment might not be reimbursed.  

Thorough medical benefit verification also ensures that the provider knows the pathway through which the drug must be sourced.  For example, while most office-administered therapies operate on a buy-and-bill model and most plans permit this, some plans may require that the medication is sourced from a specialty pharmacy.  Understanding how to best procure the drug and handle the insurance claim is essential to the clinic’s economic model.  

What makes this process particularly challenging for these offices are the specific nuances of retinal treatment. For instance, a retinal condition might occur only in one eye or bilaterally. In the latter case, prior authorization verification needs to be done individually and with specific ICD-10 diagnosis codes for each eye. Additionally, the corresponding treatments might be scheduled to occur at different times. 

The demographics of a typical retinal condition patient also accentuate the complexity of the medical benefit verification process. Since this condition is more likely to affect older adults (often requiring determination of Medicare or Medicaid benefits), and since some states reconfirm Medicaid eligibility as often as monthly, it’s important not to conduct the medical benefits verification too far ahead of the intended initial treatment date 

Why Do So Many Retina Providers Prefer CareMetx? 

Given all these complexities, retina specialists prefer to work with a hub that has experience with retina therapies and a strong understanding of the nuances of medical benefit verification. That’s why retina care providers use CareMetx’s medical benefit verification services to facilitate smooth, timely office processes. 

CareMetx works with most of the leading retina drug manufacturers and innovative retina therapies, yielding an experience base that no other hub provider can match. We’ve developed deep expertise in this therapeutic area and a keen understanding of the unique challenges of initiating retina therapy. Our team is also very knowledgeable of biosimilar specific challenges, which is critical given that many retina therapies fall into this category.  

CareMetx also brings many years of experience facilitating medical benefit verification, so we’re well-versed in navigating the nuances of retina diagnostic and billing codes and the other complexities this therapeutic area involves. 

CareMetx’s medical benefit verification is especially valuable to retina care providers, since: 

  • Our electronic medical benefit verification (MedeBV) is recognized as the industry standard because it automatically processes requests across various payer types, streamlines provider operations, and delivers fast and reliable results. With direct connections to hundreds of payers, CareMetx MedeBV results are delivered 50% of the time within seconds with 80% delivered within 4 hours*. 
  • Our high transaction volume in the retina field—over 750,000* transactions annually just in this space—speaks to the scalability and reliability of the CareMetx MedeBV solution. 
  • Our Retina Access Partner solution enables providers to receive the results of CareMetx patient access services seamlessly in their existing practice workflows, enabled with over 20 EMR / EHR integrations. This unrivaled solution facilitates an efficient, convenient therapy initiation process and a user-friendly experience for the provider. 
  • Our strong relationships with retina practices enable us to gain a deep understanding of their unique needs and their typical workflows, so we can scale our patient support services to meet their needs. 
  • Our high-touch support combines two critical components: advanced hub technology that speeds and simplifies processes, skilled, knowledgeable people who communicate with payers to ensure that the results are accurate, combined with compassion so that they understand the impact they are having on patient’s lives and deliver personalized, human-centered patient services 

Leading manufacturers and the providers they work with trust CareMetx to deliver timely, reliable medical benefit verification for the industry’s most innovative retina therapeutics. Leveraging deep relationships across the retina space, we continue to enhance our MedeBV solution and our comprehensive Hub offering—setting the standard and changing the game for specialty drug manufacturers and the providers that prescribe these therapies. 

Contact CareMetx to learn how the right hub partner can improve initiation for your retina or other specialty therapeutic. 


*Reporting provided upon request  

How Prioritizing Provider Workflow Impacts Patient Access: Inside CareMetx On-Site

How Prioritizing Provider Workflow Impacts Patient Access: Inside CareMetx On-Site

Every day, more widespread implementation of health information technology is facilitating simpler access to patient health information and rapidly...

Read More
Case Study: CareMetx Saves $12 Million for Leading Office-Based Injectable

Case Study: CareMetx Saves $12 Million for Leading Office-Based Injectable

CareMetx worked with the manufacturer of a leading office-based injectable therapeutic to manage the annual benefits reverification season quickly...

Read More
Survey Data Confirms Manufacturer Priorities for 2024

Survey Data Confirms Manufacturer Priorities for 2024

Each year, the Patient Services Survey gathers insights from pharmaceutical decision-makers, healthcare providers (HCPs), and industry consultants....

Read More