Here are five tips for maximizing contracts for orthopedic procedures. 1. Have the revenue cycle managed by high-level employees. Orthopedic surgeons often leave their billing and revenue cycle management to lower skill level employees, trusting them to accurately bill for services rendered. Unfortunately, such employees often are not educated about the best practices for billing and coding, and y may be leaving money on the table by submitting inaccurately coded claims or failing to go after denied claims.
"The education and skill set of the person who is controlling the revenue is huge, and these people must stay on top of industry changes," says Nancy Moore, president of NBP, a practice management support company. "We regularly see practices where 30 percent of their accounts receivable is lost money due to inaction "
2. Make sure surgeons are dictating all the necessary details about a procedure. When dictating, physicians should describe the surgical procedure in detail, allowing the coder to clearly visualize the entirety of the surgical encounter, says Mona Kaul, chief coding and compliance officer of GENASCIS. This should include the type of approach used (endoscopic, percutaneous, open procedure, etc.), whether the procedure was anterior or posterior, the laterality and if the surgeon operated on more than one level. Physicians should also describe any implants/graft used, and include details such as the type of implant and the number of units used (i.e., screws). Finally, the physician's report should also establish medical necessity for the procedure, which needs to be defined through diagnosis codes.
If the coder has follow-up questions regarding the documentation within the medical record, clarification should be requested from the physician. All changes to the documentation must be made in writing and added to the patient’s record for possible future reference. Do not accept verbal direction as it may be subject to interpretation and is not part of the permanent medical record.
3. Know your procedure margins and prepare to negotiate a carve-out for appropriate procedures. Knowing the margins on each procedure allows you to negotiate reimbursement for a group or procedure that is negatively impacting the surgery center's profitability. When the group or procedure has a negative impact on revenues, suggest a carve-out to achieve adequate reimbursement. This is especially important as new, more expensive technology emerges because the old reimbursement levels may no longer be sufficient. "When some technologies first start coming out, reimbursement doesn't even cover supply cost," says Tom Faith of The C/N Group. "If asking for an appropriate increase doesn't work, focus on negotiating a carve-out with the payors for recognized reimbursement."
Understanding the average cost per case at your ASC is also important if you are looking to add a new specialty or procedure type because it promotes a good dialogue as far as setting reimbursement at a level that makes since for your ASC.
4. Employ eligibility and payment tracking software. One of the ways practices most frequently lose money is by seeing patients who are not eligible to receive coverage on their treatment, says Dave Wold, CEO of Healthcare Information Services. Eligibility software allows physicians to check the availability of the patient's coverage before he or she comes into the office. The software will show the patient's coverage status and whether the patient has unmet deductibles. If the patient does not meet coverage requirements, the practice has time to speak with the patient before the appointment and make prior payment arrangements.
After a physician enters into a contract with a payor, he or she often assumes the contracts are met. However, payors sometimes underpay on contracts and losing this money can make a big difference to the practice. Mr. Wold said one of his clients recently identified over 500,000 underpayments while another discovered 100,000 instances where the payor stopped paying for a second procedure when contract guidelines stated the payor would. Payment tracking software allows the physician to enter in different negotiation schedules and then run the payments through to ensure the payor is meeting contract guidelines with each claim.
5. Create a process for dealing with denied claims. When claims are denied, orthopedic practice staff should know exactly how to deal with them. Have a process in place to locate the mistake, fix the error and then have the claim back out the door quickly so denials don't bump against filing deadlines. "In some cases, when practices receive a denial there is no activity on it because the practice hasn't staffed someone to take responsibility for denied claims," says Dave D'Silva, COO at Healthcare Information Services. "You're leaving money on the table by not fixing or appealing these claims."
Incentivize your employees to meet national benchmarks. If the staff still has trouble, you might want to consider outsourcing denied claims to achieve the best returns.
Related Articles on Orthopedic Practices:
How to Solve Cash Flow Issues: 5 Things for Orthopedic Surgeons and Practices to Know
5 Red Flags for Orthopedic Groups Recruiting New Physicians
6 Ways Orthopedic Practices Can Prepare for Young Athletes
"The education and skill set of the person who is controlling the revenue is huge, and these people must stay on top of industry changes," says Nancy Moore, president of NBP, a practice management support company. "We regularly see practices where 30 percent of their accounts receivable is lost money due to inaction "
2. Make sure surgeons are dictating all the necessary details about a procedure. When dictating, physicians should describe the surgical procedure in detail, allowing the coder to clearly visualize the entirety of the surgical encounter, says Mona Kaul, chief coding and compliance officer of GENASCIS. This should include the type of approach used (endoscopic, percutaneous, open procedure, etc.), whether the procedure was anterior or posterior, the laterality and if the surgeon operated on more than one level. Physicians should also describe any implants/graft used, and include details such as the type of implant and the number of units used (i.e., screws). Finally, the physician's report should also establish medical necessity for the procedure, which needs to be defined through diagnosis codes.
If the coder has follow-up questions regarding the documentation within the medical record, clarification should be requested from the physician. All changes to the documentation must be made in writing and added to the patient’s record for possible future reference. Do not accept verbal direction as it may be subject to interpretation and is not part of the permanent medical record.
3. Know your procedure margins and prepare to negotiate a carve-out for appropriate procedures. Knowing the margins on each procedure allows you to negotiate reimbursement for a group or procedure that is negatively impacting the surgery center's profitability. When the group or procedure has a negative impact on revenues, suggest a carve-out to achieve adequate reimbursement. This is especially important as new, more expensive technology emerges because the old reimbursement levels may no longer be sufficient. "When some technologies first start coming out, reimbursement doesn't even cover supply cost," says Tom Faith of The C/N Group. "If asking for an appropriate increase doesn't work, focus on negotiating a carve-out with the payors for recognized reimbursement."
Understanding the average cost per case at your ASC is also important if you are looking to add a new specialty or procedure type because it promotes a good dialogue as far as setting reimbursement at a level that makes since for your ASC.
4. Employ eligibility and payment tracking software. One of the ways practices most frequently lose money is by seeing patients who are not eligible to receive coverage on their treatment, says Dave Wold, CEO of Healthcare Information Services. Eligibility software allows physicians to check the availability of the patient's coverage before he or she comes into the office. The software will show the patient's coverage status and whether the patient has unmet deductibles. If the patient does not meet coverage requirements, the practice has time to speak with the patient before the appointment and make prior payment arrangements.
After a physician enters into a contract with a payor, he or she often assumes the contracts are met. However, payors sometimes underpay on contracts and losing this money can make a big difference to the practice. Mr. Wold said one of his clients recently identified over 500,000 underpayments while another discovered 100,000 instances where the payor stopped paying for a second procedure when contract guidelines stated the payor would. Payment tracking software allows the physician to enter in different negotiation schedules and then run the payments through to ensure the payor is meeting contract guidelines with each claim.
5. Create a process for dealing with denied claims. When claims are denied, orthopedic practice staff should know exactly how to deal with them. Have a process in place to locate the mistake, fix the error and then have the claim back out the door quickly so denials don't bump against filing deadlines. "In some cases, when practices receive a denial there is no activity on it because the practice hasn't staffed someone to take responsibility for denied claims," says Dave D'Silva, COO at Healthcare Information Services. "You're leaving money on the table by not fixing or appealing these claims."
Incentivize your employees to meet national benchmarks. If the staff still has trouble, you might want to consider outsourcing denied claims to achieve the best returns.
Related Articles on Orthopedic Practices:
How to Solve Cash Flow Issues: 5 Things for Orthopedic Surgeons and Practices to Know
5 Red Flags for Orthopedic Groups Recruiting New Physicians
6 Ways Orthopedic Practices Can Prepare for Young Athletes