The key to maximizing orthopedic reimbursements and striving for healthcare payment lifecycle excellence is perfecting the patient access onboarding game.  Orthopedic Patients present for treatment with an often-limited understanding of their insurance coverage and plans, as well as a sometimes confused idea of the prior authorization (PA) process and their financial responsibilities in the end.

It’s up to us to help patients navigate the process and educate them so that they can make solid, informed choices about their care. By leveraging real-time data, we can verify the patient’s insurance benefits and collect their portion upfront, while also meeting our PA obligations, and the new soon-to-be mandatory CDSM initiative (for Medicare patients).

Leveraging Data to Maximize Orthopedic Reimbursement

As healthcare consumerism continues to grow, patients are taking on more and more of the financial responsibility for their care.  Technology and automation are allowing us to present a more accurate and timely information to facilitate their financial contributions.  It’s more important than ever that the business staff responsible for onboarding patients are equipped with the most accurate data and that patient portions are collected upfront.

First Step – Insurance Verification and Benefits

The first step in this process is securing accurate and valid insurance and patient demographic information.  By utilizing a transparent insurance verification and benefits eligibility automation package, your orthopedic practice will be able to track and confirm precise patient coverage details in real-time while avoiding later denials due to ineligibility.

Utilizing a seamless integration or web portal, front office and scheduling staff would be able to access an extensive payer clearinghouse to determine:

  • a patient’s eligibility and dates of coverage,
  • their primary or secondary insurance relationship,
  • co-pay and/or co-insurance due,
  • annual deductible met and remaining, and
  • any out-of-pocket maximums

Next, Collecting Patient Portions Due

Once the patient’s insurance information is determined, it is critical for overall practice financial health that all estimated patient portions due are collected before the time of service, if possible.  Today’s consumer is conditioned to pay before receiving goods or services, but it is often the practice that neglects to ask for payment until the patient arrives or even after insurance has paid.

With strong, well-defined financial policies in place, expert collections training for staff, and clear-cut automated estimates available, patient portions collected before the time of service no longer have to slowly wind their way to either payment (often several months post-visit) or collections.  Additionally, giving patients automated payment options greatly increases payments – patient portals, apps, email notification, etc.

Are You and Your Medicare Patients Ready for CDSM?

As an orthopedic practice, you most likely have a significant Medicare population that you order advanced diagnostic procedures for, and as of 2022, CDSM certification is required for securing payment. Beginning January 1, 2022, CDSM compliance certificates will be mandatory and their omission will trigger claim rejection significantly impacting revenue. By securing an automated solution from a CMS-approved vendor, compliance doesn’t have to be complicated or overwhelming.

Often as a PA module, referring providers can provide their Appropriate Use Criteria (AUC) based diagnosis/request and submit a CDSM certificate through a bi-directional interface directly to the provider enabling both entities to bill successfully.  This same system is able to communicate with your referring provider if your organization is performing the advanced imaging tests.

Last, Prior Authorizations

By automating your PA process through an Artificial Intelligence (AI) driven software, most approvals can be obtained in real-time.  Utilizing an HL7-level interface, PAs can be submitted where appropriate, tracked, followed up, and resubmitted (if necessary) without human intervention in most cases.

What once took several hours to several weeks manually, can now be accomplished in minutes (or seconds) and unusual outliers can be followed up by expert specialists.

Unbelievably, according to the latest CAQH Index, PAs are only performed by automation in about 12% of healthcare practices.  This means a great number of practices are spending unnecessary time and resources, not to mention patient frustration, managing a burdensome and redundant system leading to denials, and lost revenue.

Streamlining the entire front-end patient access process brings improvements to not only your bottom line but also to your patients.  Their experience improves when they know and understand both your financial policies and their obligations while having easy access to payment avenues.

Contact us to schedule a demo and improve your orthopedic reimbursements—and don’t forget to explore our new CDSM Solution while the training and implementation phase is active (through December 31, 2021).