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Orthopaedic Billing Services

Tips To Improve Orthopaedic Collection Procedure And Avoid Denials

One of the most important aspects of a healthcare professional’s practice is the orthopaedic billing procedure. A proper orthopaedic billing and coding process ensures that revenue flows with minimal delays, decreasing cash flow issues and stress for your business. Denials are one of the most severe problems that orthopaedic clinics encounter, and neglecting to take preventative actions can be quite costly for your practice. Here are some orthopaedic billing and coding suggestions practice should follow to reduce the possibility of denials. Denials can completely turn your business upside down! Orthopaedic billing requires more time and concentration because it might quickly block your revenue cycle process. Proper orthopaedic billing must reduce revenue payment concerns and avoid billing delays and denials.

Orthopedic Collection Procedure 

Orthopaedic practice owners are fighting to keep their practice financially stable. There are numerous causes for this difficulty, including the fact that spending is not decreasing while reimbursement from payers is not increasing. According to a recent orthopaedic billing survey, more than 30% of orthopaedic surgery claims are presented erroneously. A large percentage of rejected and denied claims could have a negative impact on your practice’s earnings. Furthermore, more patients are choosing high-deductible health plans, which leads to increased patient accountability and, as a result, significant unpaid AR, impacting the practice’s bottom line. We discussed a few practical techniques to optimize your orthopaedic collection procedure.

Procedure Estimation

Clear patient communication regarding procedure estimates is critical to your practice’s collections. The first step toward price transparency is providing a process estimate. You can improve customer service by informing them of their financial liabilities before surgery. You should train your employees to improve patient communication and coordination. Once the surgery is decided upon, your eligibility and benefits verification team should confirm the patient’s benefits, including the outstanding deductible and out-of-pocket expenses. The majority of payers will also provide procedure estimates in real-time. You can also call insurance companies and get real-time patient eligibility and benefits updates.

To obtain the whole patient portion, try to provide the most accurate estimate feasible to patients. When you give an estimate, you must clearly state that it is an estimate and that the exact charged amount may vary depending on the payer’s policy. Most orthopaedic providers aim to collect full patient responsibility as a deposit based on estimates. Other techniques attempt to collect 50% of the patient’s liability. If your team has strong relationships with patients and is comfortable managing the entire patient part, you can gather it all at the end of the treatment. A well-informed patient on his operations and financial obligations might make better decisions regarding his procedure. Patients frequently cancel surgery at the last minute due to the inability to pay their portion. Establishing this financial relationship and discussing earlier financial arrangements results in lower patient overdue amounts.

Collection at the time of service 

Your team should be well-versed in the monetary worth of CPT codes, copays, deductibles, and total patient financial obligations. As a result, when patients check in, your personnel will be fully educated about the patient portion and can provide precise information about the services available. As previously indicated, one crucial step in collecting at the time of service is informing patients of their likely charges when they book their appointment.

You should educate your employees on how to read and understand patient eligibility and benefit information. Your employees should be able to quickly understand the remaining deductible, co-insurance, and out-of-pocket benefit information.

Evaluate the Collection Process’s Efficiency

Whether it’s the insurance or client portion, you should take a systematic method to the collecting process. Data from the collection process can be saved in various report formats. Weekly patient/insurance collections, write-off amounts-patient and insurance wise, number of refused claims, accounts receivable amounts with 30-60-90-120 days’ bucket, and other reporting formats. Establish a few collection metrics based on your practice’s needs and adhere to them strictly.

Several considerations must be made regarding orthopaedic billing to reduce errors and claim denials. Claim denials in orthopaedic billing can easily lead to insurance companies delaying payments from reaching healthcare professionals’ accounts. As a result, it’s critical to understand the risks of a claim being delayed, denied, or rejected.

Denials In Orthopaedic Billing Process 

The following are the major types of denials to avoid in orthopaedic billing:

Denials in general orthopaedic billing are classified into three types, which haunt every orthopaedic practice and highlight chances to enhance practice operations. By identifying and addressing these common issues, healthcare professionals can make informed choices that will directly impact the revenue cycle management process.

Clinical, administrative, and omission denials are the most common types of denials.

Clinical denials:

  • Medical need
  • Determination of the level of care
  • Duration of hospital stay 
  • Number of unattended follow-up visits

Administrative denials:

  • Missing or incomplete information 
  • Clarification of code 
  • Non covered services
  • Bundling
  • Request for medical records
  • Itemized Bills

Omissions Denials:

  • Inaccurate or missing prior authorization reports 
  • Incorrect demographic information or registration
  • Non-verified insurance eligibility

There are several reasons why a claim can be denied or rejected, resuming the tedious job of thoroughly checking claims, filing them back within a specific time frame, and then waiting for reimbursements. In contrast, inaccurate claims lead to a loss of reimbursements after all the waiting. As a result, it is critical that orthopaedics billing and coding be correct the first time claims are filed.

Are There Solutions Available?

Once you’ve discovered the source of your denials, the objective is to look for feasible solutions that will enhance the practice’s first claim submissions and recover the reimbursement that is presently being lost. Backtracking from the initially diagnosed pain point to the operational adjustment that will ease the situation is familiar. The simplest solution is to examine the procedure that was utilized to produce your claims in the first place. Is it effective? Is it possible to improve it through automation? Let’s take a look at three areas where we can improve:

Here are some strategies for avoiding orthopaedic claim denials:

Insurance Verification 

Any healthcare facility, especially the orthopaedics department, should verify insurance for returning and new patients. The coverage period (days), as well as the procedures/services that are eligible for reimbursement and those that are not, must be verified ahead of time. This is especially crucial because the patient must understand the charges he must pay (copays) and the insurance payments. When patients visit the hospital, the deductibles and copays must be computed and collected.


In orthopaedics, 30-40% of claims are denied owing to incorrect demographics, such as an incomplete social security number, name, address details, incorrect date or location of services performed, and incorrect NPI of the billing orthopedist, among other things. As a result, these particulars must be thoroughly checked.

Orthopaedic Codes and Modifiers 

Inappropriate diagnosis codes, updated codes, policy changes in knee and hip surgeries, CPT, HCPCS, and ICD-10 codes will always result in a denial from insurance payers if not correctly entered correctly in the claim form. Similarly, a global code with a technical modifier ensures claim rejection/denial. Modifier usage must also be supported by appropriate documentation.

Local Coverage Determinations

Maintain the ‘local coverage determination’ accessible for reference to the carrier’s local policies and procedures and if the service/item is covered/not covered on a carrier-wide basis.


Orthopaedic billing and coding must be digitized or outsourced to a third party who is a skilled biller and coder who specializes in orthopaedics claim billing. A computerized claims checker can screen claims before they are submitted. Electronic health records and claims management systems can be connected for submitting claims to insurance companies. Outsourcing companies are professionals who utilize technology (e.g., claim scrubbing software) and manual labour to review claims (e.g., coding problems) before forwarding them. With these efficient procedures in place, errors may be minimally reduced. Outsourcing orthopaedic billing services can help you save time and money, especially as you transition from ICD-9 to ICD-10 coding systems. Nowadays, most practices are willing to delegate the responsibility of billing and coding to billing partners. Orthopaedic billing and coding experts from billing companies optimize the revenue cycle process for healthcare practice. 

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