Orthopedic billing is one of the most complex areas in medical billing and coding. Understanding complex codes for separate bones, joints, and implants, and aligning them with the correct modifiers, is a significant challenge for Orthopedic practices. It affects their financial stability. For example, specifying details such as the left/right side or repeat surgeries while adhering to a specific format. If healthcare practices miss these, the chance of denials increases. Orthopedic medical billing specialists have a deeper understanding of the intricacies of orthopedic medical billing and process claims accurately. Therefore, orthopedic practices must consider outsourcing medical billing services to optimize routine operations and reduce long-term operational costs.

What are orthopedic challenges?

 

Orthopedic practices face a unique set of challenges due to the complexity of musculoskeletal procedures. Moreover, complex coding rules and continuous evolution of regulatory requirements make it more challenging to handle. Orthopedic medical billing demands specialized knowledge and precise processes to ensure accurate reimbursements. Let us discuss some specific challenges in orthopedic billing:

Navigating complex coding structures

Understanding a wide range of complex codes for specific muscles, joints, or medications is not the primary role of medical practitioners. When forced to handle these billing complexities, it disrupts practice management and takes focus away from patient care.

Monitoring follow-ups during the global period

Many medical services require bundling them in a single code because payers consider them as part of their overall procedure. However, different payers have different bundling rules. At the same time, a minor glitch or misapplying them can lead to denials, delayed payments, or compliance risks. To address this, orthopedic practices should consider outsourcing medical billing services to stay compliant with payer-specific guidelines.

Maintaining the accuracy of T-codes

Orthopedic practices offer care to a wide range of patients, including those with fractures, sprains, joint diseases, and other conditions resulting from external events or complications. Such treatments and procedures require precise T-codes. For example, the development of infection after joint replacement surgery will be reported through T-codes. Similarly, burns or skin injuries from external causes require a T-code.

Ensuring accurate documentation of complications and external causes is a significant challenge for orthopedic practices. These codes also indicate that a patient is undergoing active treatment, undergoing follow-up, or managing long-term complications. Orthopedic billing services ensure accuracy and compliance, which provides timely reimbursement, reporting, and tracking.

Dealing with claim denials

Claim denials significantly increase the workload of healthcare practices. A single claim denial costs between 25$ to over $100 to an orthopedic practice. Moreover, it slows down the cash flow of their healthcare organization while disrupting routine operations.

Complying with updated regulatory rules

Compliance with billing rules is another challenge for Orthopedic practices. Moreover, orthopedic surgeries require prior authorization to offer value-based services. However, it increases the extra workload on orthopedic medical practices. Orthopedic practices face significant administrative burdens when managing complex procedures, frequent coding updates, and strict payer rules. These challenges often translate into financial stress, reduced efficiency, and added pressure on staff.

 

Managing operational costs

In-house management of billing significantly increases the operational costs of orthopedic practices. It requires hiring extra staff to manage prior authorizations, medical coding, follow-up, and other essential tasks. Moreover, the integration of advanced technology to manage billing procedures is also expensive for orthopedic practices. Such practices add a financial burden and administrative stress on orthopedic healthcare providers. However, Outsourced billing for orthopedic practices can save operational costs in several ways. Professional billing service providers offer expert services and integrate advanced technology, saving their clients time, money, and resources.

Benefits of outsourcing medical billing

Orthopedic practices face unique financial challenges due to the complexity of their procedures and coding requirements. Upon choosing outsource medical billing services, providers can focus on patient care and enhance the patient experience. It enables them to submit claims accurately, and payments are received promptly. Outsourcing medical billing benefits healthcare practices in the following ways:

• Minimize the chances of medical coding errors.
• Improves revenue cycle management (RCM).
• Minimizes administrative costs.
• Ensure compliance with regulatory requirements.
• Higher reimbursements.
• Access to specialized services.
• Scalability.
• Improves patient care.

Outsourcing medical billing services is more than just saving cost; it is about enhancing workflow efficiency, improving patient care, and ensuring financial stability. Third-party medical billing solutions help orthopedic services with accurate claim submission, minimize claim denials, and save from payment delays. Moreover, specialized billing service providers offer advanced billing solutions, relieving musculoskeletal care facilities from substantial investments in technology infrastructure. Most importantly, it enables providers to focus more on delivering quality care to patients while handing over the billing processes to professionals.

Orthopedic revenue cycle management

Orthopedic Revenue Cycle Management (RCM) is the comprehensive management of an orthopedic practice. In this process, specialized billing teams handle all the financial aspects, including insurance verification, coding, claim submission, and denial management.

Key components of orthopedic RCM

Orthopedic RCM services cover all significant steps of the billing process, which are:

Patient registration and insurance verification: 

Billing specialists help orthopedic specialists in collecting and managing patient information. At this step, they verify patient eligibility, check coverage details, and obtain prior authorizations before the treatment. These are essential procedures to minimize denial risks and payment delays.

Medical coding

Orthopedic practices outsource medical billing services to ensure accurate translation of medical and clinical services into medical codes. Billing specialists add correct details like “both sides” or “repeat surgery to reduce the risks of denials. They precisely specify the exact bone, location, and explain whether it’s a new procedure or a follow-up visit. Such detailing ensures proper reimbursements.

Complex procedures

Some orthopedic procedures require medical codes, such as joint replacements, spinal injuries, and arthroscopies. Ensuring accuracy in all these codes is challenging for providers. Therefore, orthopedic healthcare providers outsource medical billing services to ensure accuracy in all these components.

Modifier usage

In orthopedic billing, code modifiers are used to increase transparency regarding procedures. These short codes provide additional details, such as elaborating on the part of the body that is treated. Mistakes in these codes can result in claim denials and underpayments. Medical billing specialists assist orthopedic specialists in using the correct modifiers and verifying claims using advanced software. 

Global Period Management

In orthopedic medical billing, a global period refers to the time frame during which all routine care is billed in a single transaction. In this time frame, orthopedic healthcare providers can not contact the insurance company or the payers. This duration depends on the type of procedures, varying from 0 to 90 days. To address this, orthopedic specialists face additional challenges, as such situations increase the likelihood of double charges. Such mistakes increase the chances of denials. However, outsourcing medical billing services helps orthopedic medical practices manage documentation, ensure proper payment, and avoid denials.

Bundling rules

Orthopedic specialists often utilize code bundles to prevent overcharging, streamline billing, and minimize denials. They bill for different procedures or medical services as one single code. It saves them from having to claim extra payment for the separately offered services, as that is already included in the main service. However, complying with payer-specific bundling rules is a great challenge for orthopedic healthcare service providers. To submit claims in a bundling pattern, they must stay up to date with NCCI edits to minimize the risks of claim denials.

However, professional billers help orthopedic medical professionals to comply with both healthcare regulations and payer guidelines. They use automated claim scrubbing software to detect bundling errors before claim submission.

Payer adjudication and payment posting

High-volume and complex surgeries make checking claims and recording payments more challenging for orthopedic practices. Missing modifiers or the inclusion of services in a global period can result in underpayment or claim denials. Manual reconciliation of hundreds of claims is time-consuming and prone to errors. However, professional medical billers use automated billing software to flag discrepancies, match payments, and track denials. 

Denial management and appeals

Figuring out the reason behind claim denials is challenging for Orthopedic practices. It requires the identification of outdated codes or any other disputes over medical necessity. However, professional billers address this challenge by conducting thorough investigations and resubmitting the claim while correcting the mistake. Moreover, billing specialists adopt a systematic approach to recover lost payments of orthopedic specialists. They also ensure a reduction in denial rates while maintaining a healthy revenue cycle.  

Accounts Receivable (A/R) management and follow-up

Tracking unpaid claims is a significant challenge for orthopedic practices. Orthopedic practices often offer expensive treatments, which can lead to increased complications in managing payments. It is because insurance companies often take a long time to process payments, and sometimes patients also owe money. Professional medical billers proactively follow up with insurers and manage patient payments.  They track all unpaid claims and correct errors to expedite payments. 

Patient statements and collections

Some orthopedic practices leave their patients with substantial bills, but later, patients struggle to pay. For busy medical practices, it is not easy to follow up with their patient to receive payments. In this situation, professional medical billers help orthopedic practices to create clear statements. Moreover, by utilizing advanced payment methods, they offer convenient payment options and send timely reminders to patients to facilitate timely payment. It improves collections for medical practices and allows them to focus on patient care.

Compliance monitoring

Maintaining compliance is a crucial aspect of orthopedic RCM services, enabling orthopedic practices to safeguard patient information. At the same time, RCM services help orthopedic practices to stay up to date with changing insurance guidelines. Adherence to regulations such as HIPAA minimizes financial and legal risks.

Integration of the latest technology

The use of advanced technology in orthopedic billing and revenue cycle management (RCM) helps medical practices in several ways. It optimizes their routine operations, reduces errors, and improves reimbursements. Here is the list of some key innovations and how they work:

AI and Automation

Artificial intelligence (AI) saves time and minimizes the chances of errors. The orthopedic billing uses robotic process automation to perform eligibility checks and reduce claim denials. Moreover, AI also automates medical coding, documentation, and prior authorization.

Real-time analytics

Professional medical billers use advanced software that contains dashboards to display individual patient information. Moreover, the dashboards provide comprehensive insights into the orthopedic practice’s financial performance. From these dashboards, they can also track the status of their claims, such as pending, approved, or denied. 

Integrated software platforms

Cloud-based EHR/EMR systems centralize patient data and enhance the security of patient information. The integrated software platforms simplify authorized access to patient information.

Security and compliance

Advanced technology ensures HIPAA compliance and robust data protection. The advanced billing solutions offer data encryption, access controls, and regular data backups. It provides patient data security and maintains efficient compliance.

In short, technology in orthopedic billing simplifies workflows, enhances accuracy, reduces administrative burden, and strengthens financial performance.

How to choose an orthopedic billing partner?

Orthopedic practice must consider the following key points while selecting a medical billing partner:

• Proven experience in offering services to orthopedic practices.
• Comprehensive understanding of orthopedic medical coding.
• Offers services of trained and expert staff.
• Delivers services leveraging advanced technology.
• Ensure strict adherence to regulatory guidelines such as HIPAA.
• Provides active customer support.

Conclusion

Partnering with professional medical billing services is essential for orthopedic practices to ensure better healthcare and build a strong market reputation. The billing experts significantly reduce administrative burden while handling complex coding, claim denials, and payment collections. These help orthopedic providers to maintain HIPAA compliance and focus more on patient care. The services play a significant role in preserving workflow efficiency and maintaining financial stability.