Three Major Challenges for Orthopedic RCM

As orthopedic practices continue to grapple with changing payment structures and strategic partnership opportunities, Revenue Cycle Management (RCM) continues to be the single biggest concern outside of patient care. Exceptional RCM workflow and resolution provides orthopedic organizations with the cash flow required to run their operations successfully, but also build capital reserves so that they can expand where opportunities exist.

Today’s ortho patients are assuming a larger portion of the financial responsibility through high deductible insurance plans that have lower monthly premiums, but significantly higher out-of-pocket costs and annual maximums. This has created a healthcare consumer that is knowledgeable, inquisitive, and willing to pay in advance given accurate, trustworthy, and timely information.

What is the best way to capitalize on this new engaged consumer relationship during a time of declining revenues and evolving reimbursement structures?

Orthopedic RCM Challenges

By identifying key orthopedic RCM pain points that interfere with maximized reimbursement, we can begin to formulate answers that are cost-effective and provide multi-tiered solutions to everyday frustrations. While analyzing current systems, it’s important to look at the workflow, the people affected, and how efficiencies can be gained through technology and automation.

Let’s look at three RCM bottlenecks that can be improved or eliminated and will capture leaking revenue that belongs in your bottom-line results:

Prior Authorization

The prior authorization (PA) function is estimated to create over 16 hours of work per healthcare provider each week according to a recent AMA survey. In a specialty such as orthopedics, that number can climb to 25 to 30 hours depending on the type of practice. With nearly 60% of patients waiting at least one day and up to five days for approval, PAs lead to patient and provider frustration and ultimately care abandonment.

Automating the PA process may be the single most impactful change an ortho practice can make—it frees up abundant time where staff members can be actively engaged with patients, reduces denials, and ensures prompt reimbursement. Today’s automation options include artificial intelligence and machine learning software to streamline and accelerate the entire process in the following ways:

  • Determining if a PA is required, or not
  • Initiating and submitting a PA request if needed
  • Automated status checks and follow-up with payers
  • Updating approval status in real-time to reduce cancellations and rescheduling of patients


Another outsized orthopedic RCM challenge is ensuring well-managed, timely, and precise ICD-10 coding. Staying current and ensuring that staff members are educated on pertinent coding issues is an endless task and one that remains critical to capturing reimbursement at rates that equal contracted amounts.

Many ortho practices are finding that marrying a third-party partner with in-house management is the best way to improve coding results. The other significant benefit to a fresh pair of eyes looking at your coding process is ongoing audits that can diagnose under coding or not coding to the highest level of specificity, unbundling habits, or overuse of codes.

Denials Management

Having a strong denials management software solution helps secure payment on claims that are rejected by insurance payers for a variety of reasons. Managing denials is often relegated to a secondary or tertiary level of importance due to difficulty in obtaining missing information or perceived effectiveness leading to neglect or desertion. Often, business office staff simply turn their attention to the most emergent function and the arduous task of investigating and correcting old, rejected claims falls to the bottom of the “to-do list”.

Automating the denials management process using artificial intelligence enhanced software can predict the next action on a per-claim basis, streamlining efforts by priority and likelihood of success. By using predictive learning based on payers’ rules and guidelines, you can maximize the effort required to follow up on unpaid claims bringing more revenue to the bottom line.

With the advances that are being made through automated, AI-driven solutions, orthopedic RCM problems can be easily solved, and provider and staff time freed up to focus on the patient experience.

If you want to know more, contact us to schedule a demo to discuss orthopedic RCM solutions that would benefit your organization.

About the Author

Infinx Healthcare provides innovative and scalable payment lifecycle solutions for healthcare practices. Combining an intelligent, cloud-based platform driven by AI with our trained and certified coding and billing specialists, we help clients realize revenue, enabling them to shift focus from administrative details to billable patient care.

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