Optimize Your ASC’s Revenue: Avoid These Five Orthopedic Billing Errors

ASCs specializing in orthopedic procedures must navigate intricate billing and coding requirements. Oversights in these areas can lead to significant revenue losses. Let’s delve into five common orthopedic billing errors and the best practices that will safeguard your ASC’s financial health.

Let’s delve into some common orthopedic billing errors that plague ASCs and explore actionable solutions to combat them.

1. Inadequate Understanding of Payer Contracts

Knowing the terms of your payer contracts is paramount. Issues like claim submission deadlines, allowable procedures, reimbursement methodologies, and processes for appealing denials must be crystal clear to your billing team. Failure to grasp these details can result in delayed payments, underpayments, and missed revenue opportunities.

Solution:

• Maintain Detailed Records: Keep a comprehensive and easily accessible record of all payer contracts.
• Train Your Team: Conduct regular training sessions on contract specifics, ensuring your billing staff is equipped with up-to-date knowledge.
• Renegotiate When Necessary: Don’t hesitate to negotiate fairer contract terms when the opportunity arises, especially when facing consistent underpayments.

2. Errors in Coding

Orthopedic procedures involve intricate coding. Using incorrect CPT (Current Procedural Terminology) codes, neglecting modifiers, or misrepresenting procedural details can cause claim rejections or underpayments.

Solution:

• Invest in Expert Coders: Employ certified coders specializing in orthopedic procedures to ensure accurate and comprehensive coding.
• Stay Current on Updates: Regularly attend coding webinars and training sessions to keep abreast of the latest CPT changes and coding guidelines.
• Double-Check Coding: Implement a system where a second coder reviews all claims before submission for an extra layer of quality control.

3. Incomplete or Incorrect Patient Information

Typos, missing information, or outdated demographic data can cause automatic claim rejections. Seemingly minor mistakes create a major hindrance to efficient reimbursement.

Solution:

• Diligent Verification: Thoroughly verify patient information at the time of scheduling and update records as needed.
• Pre-Registration Process: Establish a pre-registration process where patients can complete and review their personal information in advance.
• Technological Aids: Consider utilizing electronic health record (EHR) systems with built-in validation tools to catch errors before claims go out.

4. Missed Prior Authorizations

Many orthopedic procedures require prior authorization from insurance payers. Submitting claims without this crucial step leads to guaranteed denials and frustrating delays.

Solution:

• Develop Clear Processes: Outline a well-defined process for identifying procedures that require prior authorization and tracking the status of requests.
• Assign Responsibility: Designate specific staff members to handle prior authorizations and ensure they have the necessary payer contact information.
• Stay Ahead: Obtain prior authorization well in advance of the scheduled procedure to avoid last-minute complications.

5. Failure to Appeal Denials

Don’t let denied claims go unchallenged. Many denials are the result of minor errors or missing information that can be rectified. A robust appeals process is essential to maximizing reimbursement.

Solution:

• Track Denials: Implement a system to track denied claims, including the reason for denial and relevant payer information.
• Analyze Trends: Identify recurring denial patterns to pinpoint systemic issues that need to be addressed.
• Build Your Case: Gather thorough documentation to support your appeal and submit it promptly, adhering to the payer’s appeal deadlines.

Additional Tips:

• Embrace Technology: Consider investing in billing software specifically designed for ASCs to streamline processes and reduce errors.
• Partner with a Specialist: Outsource orthopedic billing to a reputable third-party company if managing complexities becomes overwhelming.

Mastering the Revenue Cycle for ASC Success

Consistently achieving a smooth-running revenue cycle requires diligence and strategic adjustments. Remember, even small oversights can significantly impact an ASC’s financial health. Here’s a quick recap of some common revenue cycle pitfalls to avoid:

• Coding Missteps: Inaccurate coding, missed modifiers, and mismatched surgeon/ASC codes lead to claim complications and lost revenue.
• Incomplete Patient Records: Disorganized documentation creates a bottleneck for coders and billers.
• Out-of-Network Payment Confusion: Pre-negotiate rates and document agreements with insurers.
• Unfavorable Payer Contracts: Advocate for fair reimbursement terms during negotiations.
• Payment Posting Delays: Stay on top of payment posting and reconciliation to prevent revenue leakage.
• Lack of KPI Tracking: Monitor crucial metrics like charge lag and A/R over 90 days.
• Appeals Overlooked: Challenge incorrect payments promptly, especially when contracted rates are violated.
• Unreconciled Billing: Ensure all procedures are billed and track the reasons for any unbilled cases.
• Missed Authorizations: Always secure prior authorizations, especially for implants and expensive procedures.
• Neglecting LCDs: Familiarize yourself with Local Coverage Determinations to ensure your documentation is compliant.

By staying vigilant against these challenges and using the outlined strategies, your ASC can gain a significant edge in optimizing revenue, maintaining profitability, and, ultimately, delivering the best possible orthopedic care.