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

March 28, 2013

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

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.

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Category : Revenue Cycle Management