Today, the US healthcare system spends an extraordinary amount of total healthcare dollars on administrative costs; billing, insurance management, and hospital/practice administration. Estimates suggest as high as 30% industry-wide, and it’s directly related to the complex, third-party payer system that has evolved.
To search for solutions leads one to the denials report where stress points within the system are visible if you look at the detail. According to the Medical Group Management Association (MGMA), 50 to 60% of all denials are never worked and left to languish until they are written off as bad debt. This leads to the conclusion that adequate time isn’t being given to the denials report as a source of possible operational improvement.
3 Types of Denials to Avoid in Orthopedic Billing
There are generally three categories of denials that haunt every orthopedic practice and each category demonstrates where there are opportunities for improvement of practice operations. By isolating where these problems are occurring, your practice has an opportunity to make solid improvements that will directly affect the bottom-line.
- Clinical Denials —
- Medical necessity
- Level of care determination
- Length of stay for hospital visits
- Number of follow up visits not adhered to
- Administrative Denials —
- Missing information
- Coding clarification – invalid, inaccurate, or missing codes
- Not a covered service
- Untimely filing
- Requests for medical records
- Itemized bills
- Omission Denials —
- Missing or incorrect prior authorizations
- Registration or demographic inaccuracies
- Insurance ineligibility
Are There Solutions Available?
So once you have identified where your denials are being generated, the key is to look for workable solutions that will improve the practice’s initial claims submissions and capture the reimbursement currently being forfeited. It’s often a case of backtracking from the initially identified pain point to the operational improvement that will alleviate the problem.
Often the most obvious solution is to look at the process being used to generate your claims originally. Is it efficient? Can it be improved through automation? Let’s look at three opportunities for improvement:
One significant reason for denied claims is missing or incomplete prior authorizations (PAs). This is often because patients arrive in your orthopedic practice without PAs from the referring doctor, and none are obtained before proceeding with care.
Rather than chase down the necessary paperwork, why not engage an advanced automation solution that leverages artificial intelligence (AI) to determine if a PA is required, process and submit appropriate information to the payer, and then provide 24/7 monitoring and follow-up. In this environment, PAs that used to require hours or days to complete can now be done in minutes with this type of tech-enabled service solution, saving hours of administrative time and effort.
Insurance Verification and Benefits Eligibility
The demographics collections process can be done manually or electronically. Still, once the information is in hand, digital verification and benefits eligibility is critical to manage the patient access process efficiently. When this information is electronically checked before each encounter, denials nosedive for this type of problem.
As a bonus, this also lends itself to collecting the patient portion at the time of service (or before) since you are working with accurate and up-to-date information.
Billing and Coding in the Most Effective Manner
Once the patient’s visit is complete and the provider’s documentation is done, then the coding and billing team takes over. If this process isn’t done precisely, then any number of denials can occur.
Consider engaging a third-party coding and billing group with certified billing specialists that maintain their training and certifications and operate at the highest level. With clean coding and billing, there can be a major improvement to the denials management process.
According to the MGMA, reworking a denial costs a practice of $25.00 for each occurrence. The key is to prevent them in the first place.
Contact Infinx to learn more about avoiding denials for your orthopedic practice using advanced automation and AI-driven software.