Responding To Growth-Induced Orthopedic Medical Billing Needs with Specialist Intervention

Orthopedics have been on upward growth trajectory thanks to a host of conducive factors – continued pro-orthopedic Medicare reimbursement reforms, innovative care procedures, breakthroughs in orthopedic technology and anesthesia administration have largely been responsible for upsurge in practice volumes. The combination of these factors has enabled shifting orthopedic from hospital-based inpatient form to a more popular and affordable form – outpatient or ambulatory settings. It is noteworthy that this form of orthopedic care is currently growing at over 20%, which is comparable with other fastest growing specialties.

While orthopedic practitioners have reasons to be upbeat about their practice prospects, they should equally be cautious and prepared for billing complexities that may be accompanying the swelling practice volumes.

-->

One of the primary reasons why Orthopedic Billing may be susceptible to billing complexities is that orthopedic comprises a broad spectrum of procedures to treat a variety of orthopedic conditions, which are perceived and valued differently by payers. Therefore, it would require orthopedic practitioners to be versatile to respond with orthopedic billing and coding in conformity with individual perception of the payer who they are submitting their claim to. More than mere submission of claims, they should necessarily have a systematic Revenue Cycle Management with comprehensive processes such as coding, charge posting, claims filing, payment posting, A/R follow-up including denial management, and reporting.

Significantly, insurance underpayments, which are more rampant in orthopedic and as high as 10 to 15% of the actual claims, may push orthopedic practices into a state of revenue erosion that could jeopardize their clinical and operational efficiency. As a result, they might have to emphasize on monitoring and minimizing underpayments with an effective process of credentialing, verification, patient eligibility, and proper coding & billing.

Browse all : Medical Billing Blog

Coding revisions too would substantially add up to Orthopedic Billing woes – with the on-set ICD-10, orthopedic codes will be more complex, detailed, and numerically too many to code a wide array of orthopedic procedures such as bone graft, open surgical partial removal of collar bone, partial repair or removal of shoulder bone, open repair of rotator cuff, open repair of rotator cuff, reconstruction rotator cuff, open repair elbow fracture involving ulnar bone, wrist fracture pinning through skin, open surgical treatment wrist fracture, shoulder scope, repair cartilage tear, shoulder scope, partial removal collar bone, shoulder scope, bone shaving, shoulder scope, rotator cuff repair, injection of lower back joint, and many more. This monumental coding revision might warrant appointment of specialist coding professionals.

The changing orthopedic coding and billing landscape would require, among various other things,

To evaluate where you stand currently as against the projected requirements for a comprehensive orthopedic RCM comprising coding, charge posting, claims filing, payment posting, A/R follow-up including denial management, and reporting.

To earmark resources to monitor finances, and assigning them the responsibility of meeting with patients before admission to pre-collect copays, deductibles and co-insurance amounts, and work out payment plans as needed.

To improve front-end revenue cycle management, comprising checking coverage and verifying patient information before hand.

To facilitate training coders on coding revisions as and when they happen.

As in the case of most busy and critical medical disciplines, orthopedics may also be bound by an overriding clinical focus that may be limiting their exposure to full-pledged orthopedic medical billing reforms. Medicalbillersandcoders.com – having successfully mediated resource-deployment for growth-induced medical billing requirements across the broad spectrum of medical disciplines – offers to replicate it in orthopedics too. With an affiliation with chosen pool of orthopedic medical billing specialists across the 50 states in the U.S., orthopedics can expect to have instant access to specialist medical billing services.

Insurance Underpayments, the Issue That is Plaguing Orthopedic Billing the Most

Insurance underpayments continues to be a major concern for medical practices across the United States; more so for orthopedic surgeons, who, despite serving in a more critical specialty, find it hard to fully recover their medical cost. Because most of the orthopedic procedures happen to be highly expensive, even a marginal percentage of insurance underpayments might turn out to be a major drain on practitioners’ revenue, which could severely spoil clinical and operational efficiency. With orthopedic surgeons’ insurance underpayments touching an all-time high of 10 percent and potentiality to reach 20 percent, it may be time that orthopedic surgeons relooked at their medical billing practices and process, and aggressively track and resolve their underpayments. It is encouraging that significant portion of these underpayments (as high as 7 to 10 percent) can easily be made good with a refined and robust orthopedic-specific medical billing.

While most of the underpayments may be linked to refusal by the insurance carriers, the root-cause may be inherent in orthopedic surgeons’ medical billing policies and procedures: Orthopedic Billing

To begin with orthopedic surgeons may have not been enrolled and approved by insurers.

They may not have taken due diligence in verifying patients’ eligibility for services prior to the actual appointment; there could have been lack of technology integration with practice management system to verify coverage for patients’ orthopedic procedures.

Orthopedic surgeons may have not been cautious in seeing pre-authorization or precertification, in the absence which payers are automatically authorized to reject payments for  procedures and services even if they have been proved to be medically necessary.

Orthopedic surgeons’ staff may have left deductible or coinsurance uncollected from patients.

Major portion of patients may have been Medicare and Medicaid beneficiaries, whose reimbursements are lower than most of the popular commercial insurance plans.

There could have been coding errors (either under-coding or over-coding) due to coding staff’s incompetence. And with orthopedic coding likely to be more complex and vast post ICD-10, the scope for coding may be even more.

There could have been considerable in claim submission, so much so that insurance payers could reject them on grounds of being too late to be accepted.

Lack of denial management too may have been another reason; it takes special expertise to track and follow up denials in a system characterized by multiple payers

-->

Browse All: Orthopedic Billing

It really takes an effective system to monitor and compare underpayments against contracted fee schedules, be it is Medicare, Medicaid or popular commercial health plans. The reasons for underpayments such as the ones highlighted can only be unearthed through a careful analysis of Revenue Cycle Management processes employed by orthopedic surgeons.

Medicalbillersandcoders.com – which has been a resource center for comprehensive medical billing solutions – can mediate the deployment of resources (orthopedic billing specialists) that offer remedial solutions to underpayment issue plaguing the orthopedic surgeons. Significant of advantage of sourcing resources through our platform is that you will get discover the real reason for a decrease in revenue; problems that should be addressed such as credentialing, insurance verification/precertification, collections, coding, and payer mix; and recognize the reasons for denials and comparing payments to the fee schedule to resolve issues with payers.

The Demands of Value-Based Reimbursement Model to Be Met With Medical Billing Specialists

With many of the healthcare reforms set to take effect shortly or having already been in force, providers may have entered a different phase of operational model, which is called value-based model. The unique feature of value-based model is that providers will get reimbursed for delivering superior medical care at a progressively lesser cost. As the public plans such as Medicare, Medicaid, and most of the commercial plans are likely to adopt value-based reimbursement models, it may be inevitable for providers to shift over or find a balance between fee-for-service model and value-based model in order to sustain profitable clinical practices.

To being with, you have Medicare's value-based payment modifier that will be launched for physicians in groups of 100 or more in 2015. The unique thing about this modified value-based payment model is that it works on the principle of ‘carrot and stick’ theory, meaning physicians may either be eligible for either positive or negative payment adjustment depending on their level of compliance with care quality and reporting. To prepare for the eventual 2015 model, it may even be necessary to demonstrate capability for PQRS reporting, beginning as early as 2013. Furthermore, the performance post 2015 will be significant as most of the value-based returns will start yielding from 2017 based on the PQRS reporting post 2015.

While Medicare and Medicaid reimbursements have already begun experimenting with ACO model as a superior form of reimbursing physicians for their services to public healthcare plan beneficiaries, commercial payers, sooner or later, too will be obliged to adopt modified versions of reimbursements. Therefore, providers will have to plan, be prepared and resourceful enough to realize their reimbursements from both public as well as commercial insurance payers.

As far as planning goes, it should all start with:

Thorough evaluation of payer market to find out what value-based payment opportunities await down the line. It may also be important to know the dynamics of payers’ reimbursement methodologies.

Assessment of your current documenting, coding, and billing practices against the requisite standards, dictated by the changing payment models.

Planning progress to the expected level through a phased manner.

Once you have the plan in place to progress to value-based payment model, providers may actually start implementation with:

Value addition to care delivery: It means minimizing the possibility of recurrence of medical conditions. When providers are able to minimize the recurrence, it would contribute to substantially savings in reimbursements that might happily shared by payers with responsible providers.

Better care coordination: Coordinated care, involving physicians and support staff will likely facilitate better clinical outcomes, which are often deemed fit for specials incentives along with regular reimbursements by payers.

Extending patient reach and engagement: When providers begin exploring opportunities to increase their and involvement, it is definitely going to improve care quality, which is the fulcrum for deciding the value-based reimbursements.

Forming new clinical alliances: The value that clinical alliances bring to clinical quality is really unquestionable and the providers’ success as value-based providers will largely depend on how best they network their clinical services with competent specialists.

As providers find themselves engrossed with value-based clinical activities, it may require a dedicated medical billing to look after the process of documenting, coding, and billing claims for value-based reimbursements.

Medicalbillersandcoders.com – with a nation affiliation with resources (medical billing specialists) that can own and execute medical billing functions on behalf of providers stuck in the process of migrating from fee-for-service model and value-based model – offers to mediate the deployment of competent, experienced and versatile medical billing specialists that could effectively look after the operational side of value-based reimbursement model while providers concentrate on the clinical aspect.

Orthopedic Billing Specialist to Take Care of CPT Code Changes Made to Orthopedic Surgery Billing in 2013

This year’s CPT Manual has spelt out extensive coding changes and revisions to orthopedic surgical codes.  In all, there are 500 code changes to the Category I codes, including 251 revisions, 151 new codes and 100 deletions. Moreover, there has been significant overhauling of nerve conduction studies, some revisions to the radiology section, and E/M changes. The extent of these coding changes and revisions, having already taken effect from January 1, 2013, has begun to impact orthopedic reimbursements in a big way. As a result, orthopedic practices may have inherited an ominous task of migrating to   a higher order in orthopedic surgical coding. Given the CPT Manual’s full list of revisions, deletions, and additions to have been effected for 2013, orthopedic practices would require to be conversant with the guidelines for the following coding sections:

Spine CPT Errata, whereinchange has been added to the spine bone grafts (20930–20938), instrumentation (22840–22844, 22848, 22845–22847), and intervertebral device (22851) CPT codes.

Bone marrow aspirate, wherein explanation has been added to bone graft codes (20930–20938) related to bone marrow aspiration. Henceforth, Category III code 0232T should be used when bone marrow aspiration is performed for platelet-rich stem cell.

Cervical Spinal Arthrodesis, which is now required to be coded as per the new guidelines issued to CPT codes 22554, 22585, 63075, and 63076

Cast application, which now includesguideline changes made to “Application and Strapping” section addressing the application of the first cast, its removal, coding by the individual who performs the initial service, and restorative management.

Hip arthroscopy, under whichCPT code 29916 (Arthroscopic labral repair of a torn labrum) is now considered inherent to CPT codes 29915, 29862, and 29863.

Chemodenervation, in which a new guideline change is introduced for CPT code 64614 used in  Chemodenervation of muscle(s); extremity and/or trunk muscle(s)

Intraoperative nerve monitoring is now included in the primary surgical service and is not separately reportable.

New CPT codes applicable to procedures for spine, shoulder arthroplasty, elbow arthroplasty, nerve conduction, extracorporeal shock wave: wound healing, etc.

Borwse All : Medical billing blog

While these are some of the notable changes and guidelines to have been effected for orthopedic surgical coding since the beginning of 2013, orthopedic practices may need to follow these action steps to be fully compliant with the changes and revisions:

• Analyze the 2013 CPT Manual in its entirety to understand the guideline changes found throughout it. Specifically focus on the E&M changes and new codes that may have applicability to your practice.
  
  
• Revise charge capture tools, electronic health record (EHR) lists and short lists or favorites, if charge capture is performed within the EHR.
  
  
• Enroll with an accredited orthopedic surgical coding course.

Medicalbillersandcoders.com – which has always stood by the physician community during times of medical billing and coding crisis – has arranged for networking with the right resources (orthopedic coding specialists) to maneuver through this major surgical orthopedic coding changes and revisions. The competence and experience of our select pool of surgical Orthopedic Billing specialists should help you minimize the impact of this coding change and revision while ensuring appreciable increase in orthopedic reimbursements.

Negotiating Your Reimbursement Rates during this Phase of Payer Consolidation & Health Insurer Monopoly Power

Physicians’ choice of health plans and contracts seem to be getting fewer and fewer with each passing moment as U.S. health insurance sector, particularly the private sector, witnesses unprecedented payer consolidation, acquisitions, and mergers amongst private health insurance carriers. Besides contradicting the hope that such consolidation, acquisitions, and mergers would bring down the cost premiums for patients, it has virtually helped a few players to wield monopoly over the entire commercial health insurance landscape. The situation has grown so unchecked 70 percent of 385 metropolitan areas in the U.S. do not have competitive conditions, and as much as 40 percent of these areas have a single health insurer controlling the majority share of the commercial health insurance market. As a result, physicians have virtually lost the bargaining leverage that they would have enforced had there been a perfect competitive market for commercial plans.

Physicians only source of revenue is from reimbursements from services they offer to patients, who may be supported commercial health insurance plans or public programs, such as Medicaid and Medicare. With most of the commercial health insurance market moving toward monopoly, physicians, mostly those practicing in small groups, are finding it difficult to negotiate adequate reimbursements. As a result, those insurers with monopoly powers are dictating the payment rates, which are often below the acceptable scale. Such unilateral administration of payments could leave physicians struggling to meet their financial obligations, obligations, including payroll, and to invest in and sustain desirable quality of medical care to their patients.

Browse All : Medical Billing Blog

Even the thought of accepting public insurance plans may not prove to be all that profitable – most of the patients may not have the resources to pay for out-of-pocket expenses well above the rates borne public programs, such as Medicare and Medicaid, whose rates are deemed insufficient to cover for a decent quality of medical cost. Thus, small physicians are often left with no choice but to accept rates dictated by dominant commercial insurers.

While the physicians associations have voiced strong protest against health insurer consolidations, in particular, mergers between two health insurers which threaten to create a single insurer with absolute power, it may take a while to disintegrate the trend towards a competitive market that can bring back bargaining power to physicians and patients alike. Till such time, physicians may well have to be content with rates as fixed their commercial payer. Alternatively, they can entrust their Medical Billing processes to an external entity that can use its competence and experience to arrive at as profitable a rate as possible. 

Medicalbillersandcoders.com – which has been a preferred platform for comprehensive medical billing resources – can help physicians impacted with the trend of commercial insurance consolidation. Our nation-wide affiliation with chosen pool of medical billing experts helps us to deploy resources that enhance medical billing efficiency, reduce the possibility of delay, denials, and improve practice revenues. Their expertise and experience could easily be extended for negotiating as best a reimbursement rate as possible even at this juncture of commercial payer monopoly.