Orthopedic practices with a high volume of surgeries and knee injections must code carefully to win reimbursements from payers. With average costs of over one thousand dollars for viscosupplementation drugs and tens of thousands for knee surgeries, payers usually request squeaky clean claims and prior authorizations for common orthopedic procedures.
The strict medical necessity criteria they insist on includes documented imaging of joint damage, significant impact on mobility, and failure of conservative medications and physical therapy. Without this documentation, claims and prior authorizations are denied and appeals can take weeks to resolve–if they don’t get written off entirely.
Busy Orthopedics Center Baffled By Revenue Struggles
A five-doctor practice in Plano, Texas had so many denials that—although popular—their knee injection services struggled to turn a profit. This orthopedics and sports medicine center prides itself on a roster of doctors that consistently train in the most innovative techniques and technologies from around the world. Its doctors have degrees from Harvard, the University of Southern California, Baylor, and more prestigious institutions. After receiving a referral from another Texas orthopedic practice utilizing our solutions, the group partnered with us to address its prior authorization challenges.
With dozens of knee injections and surgeries scheduled every week, the practice had accumulated a backlog of prior authorizations and claims that were interfering with patient access and throughput.
The doctors and staff were working hard. While they met with 50 patients each day, just 20 of those turned into scheduled procedures–a typical medical practice conversion rate. With ten of these procedures returning diminished revenue, the practice struggled to offset costs.
Revenue Health Check Pinpoints Sources Of Revenue Leakage
We began by conducting an intense review of all steps in the revenue cycle from prior authorization and eligibility through billing and collections. This review was conducted by our premier orthopedic coding specialist who is a former surgeon. Without a complete revenue cycle management system, management had no visibility into productivity, time to completion, or the location of bottlenecks. They were blind to which procedures brought in the most revenue and where their revenue was leaking.
We quickly identified the areas that were most responsible for the rampant denials: prior authorizations and coding. For prior authorizations, the physicians and staff were only including the CPT codes for the main procedure they intended to perform. As occurs in many orthopedic centers, once the surgery began, surgeons often needed additional procedures to fully treat the patient’s issues.
Committed to the best patient outcomes, orthopedic surgeons would carry out the procedures while knowing they would likely not be reimbursed. The billing company handling the prior authorizations went with these limited CPT codes without recommending that they expand them to better recoup revenue.
Incomplete, Inaccurate Claims Coding Leads To Revenue Losses
Many denials also originated from under-coded, under-documented, and inaccurately coded claims. We shared these findings with the client and revealed just how much revenue they were losing.
We discovered that, with surgeries complete, the doctors were working from memory sometimes weeks later, jotting down general codes based on what they typically coded for similar surgeries. This habit often missed a significant number of procedures they had actually performed. Again, the billing company was simply copying the doctors’ CPT codes into the claims without any charge reconciliation.
Next, we reviewed for coding inaccuracies, which were rampant. While these errors originated with staff and surgeons, the billing company failed to catch them. Physicians’ lack of coding expertise and up-to-date awareness of current coding changes were causing the errors that got claims denied.
To prevent denials triggered by under-coded or inaccurately coded claims, the patient’s claim must demonstrate the correct status, the correct location, as well as the correct CPT and ICD-10-CM codes to support medical necessity. It must also match with the provider’s documentation. Errors in these many details prompt denials.
To address the unsustainable revenue loss due to incomplete prior authorizations and poor claims coding, the orthopedic practice chose to partner with us for prior authorization and full spectrum revenue cycle services, including charge capture, coding, A/R recovery and denial management and more.
Infinx Streamlines Prior Authorization Processes
Our first step was to tackle the prior authorization backlog. During this process, we began listing any codes for procedures that could possibly arise in addition to the initially diagnosed procedure. This step helped cut the need for retroactive prior authorizations, saving staff time and labor costs.
The new solution gave staff a single prior authorization platform that guides them through the proper submission of prior authorizations and claims according to payer. This assistance speeds the prior authorization process dramatically.
The live dashboard provided managers with an overall aerial view of all prior authorizations and claims, as well as their turnaround times so they could make informed operations decisions. The analytics available now drive staff productivity and improve throughput.
Comprehensive Expert RCM Services Maximize Revenue
To ensure coding consistency for both our team and the practice, coding team supervisors created custom standard operating procedures (SOP) for every modality. That way, whether the practice needs to code for an x-ray, a DME need, or any other procedures, clear steps exist for how to do so accurately.
At the same time, the team educated the practice’s in-house team about coding correctly according to the diagnosis, what place of service it needs to go to, and what constituted complete documentation for various payers. These more efficient workflows help ease the staffs’ workloads significantly.
Today, we handle a portion of their office and hospital charge entry, payment posting, denial review and remedy, appeal and re-file orthopedic surgery claims on complex surgeries, and more.
Practice Revenue Leaps 44% Within Two Years
When we entered into a partnership with the practice in the last quarter of 2019, the group’s year-to-date collections stood at $2,757,801. By the end of 2020 with our revenue cycle management in place, collections had grown to $3,315,806. By the end of 2021, collections rose to $3,967,527. This increase of $1.2 million amounts to a 44% improvement in just two years. These improvements came from optimizing each element of their revenue cycle, especially the broken prior authorization, charge capture, and coding processes.
Beyond the numbers, improved in-house staff’s coding expertise has reduced denials from the outset. When new staff members onboard, they have consistent standard operating procedures to use for every submission. They know when and how to bill accurately on DME, an area where they were losing money quarter after quarter. Their payers’ requirements for medical documents have diminished because this practice has won a reputation for being conscientious and thorough about documentation.
Best of all, patients at the orthopedic practice are reporting increased satisfaction with their doctors and procedures. With a faster prior authorization turnaround time, patients can see doctors sooner to relieve their pain. This access to better care ensures them more peace of mind, greater mobility, and better quality of life.