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Critical Role of Insurance Verification Process in Orthopedic Practices

Orthopedic revenue cycle management has been seriously impacted by the changes taking place in the healthcare industry such as reduced physician reimbursement, payers negotiating fee-for-service contracts, meaningful use and so on. Orthopedic practices need to work hard to improve their revenue cycle processes. The process of verifying patient insurance is important when it comes to addressing these challenges and receiving maximum reimbursement for services provided to patients. Strategic changes have to be implemented in the revenue cycle processes to enhance your practice’s bottom line. Before going into this, let’s take a look at the challenges orthopedic practices face in 2015 and how insurance verification becomes very important.

Biggest Challenges for Orthopedic Practices in 2015

Though there are many distinct challenges this year when billing for orthopedic services, the biggest ones among them are as follows.

  • Patient Protection and Affordable Care Act (PPACA) – The four components of PPACA have a significant impact on U.S. healthcare insurance industry. First, it expands coverage to Americans having no healthcare coverage with associated mandates and insists on employer penalties if the coverage is not given to employees. Second, insurance exchanges in states are utilized to achieve expanded coverage. Third, the costs of expanded coverage are subsidized by increased taxes and decreased payments to providers. Fourth, financing additional expenses for this extended coverage takes place secondary to the increased taxes and reduced provider payments.
  • Declining Reimbursement Rates – According to the American Academy of Orthopedic Surgeons (AAOS), there was a 30 percent drop in reimbursement rates for Medicare physicians from 1992 to 2010. As said earlier, physician reimbursements are reduced to compensate with additional coverage of PPACA. Increasing difficulty in gaining out-of-network reimbursement is another reason for reduced reimbursement rates. The other reason is the increased competition for ancillary service revenues. Majority of orthopedic procedures can be performed as outpatient surgery and hospitals cost more than ambulatory surgery centers for outpatient surgery. Due to this, patients opt for ancillary services and the payment for orthopedic surgeons in hospital-based practices will decrease.
  • Costs for Implants – The costs for implants are continuing to increase as new technologies emerge (for example, biologics, minimally invasive) while the insurance contracts do not. As a result, the high cost of new technologies strain budgets of practices instead of giving them a financial gain.

A thorough verification of patient insurance can help practices have a clear picture regarding these challenges and ensure they will receive decent reimbursement. Benefit verification and pre-certification are the two important areas that orthopedic practices must focus on when it comes to improving reimbursements.

Benefit Verification
Verifying your patient’s benefits can lower the claim denials from payers as it will help you to know whether you will be paid appropriately for the services provided or paid at all. With thorough benefit verification, you can know whether out-of-network reimbursement is provided, details about out-of-pocket costs (co-pays, co-insurance, deductibles) as well as tax subsidies and whether the patient holds both primary and secondary insurance. You should obtain the benefit information before a patient arrives for an appointment and ensure that information is accurate. Here are some best practices to ensure your verification process works optimally.

  • Find out the best resource, typically online according to the insurance plan
  • If you require detailed information, call the insurance company representative instead of browsing the website or relying on an automated system
  • Know what questions you should ask to obtain the correct benefit information regarding your patient

Obtaining the services of a professional, experienced insurance verifier will help ensure an effective benefit verification process.

Now, many insurance carriers insist on prior authorization or pre-certification for more procedures and services. However, a study published in the Journal of the American Board of Family Medicine reveals the cost for prior authorization activities, per full-time equivalent physician to be between $2,161 and $3,430 a year. The study also found prior authorization is a measurable burden on physician as well as staff time.

Thus, the process of getting prior authorization is challenging and time-consuming. To make matters worse, many insurers follow a policy to disallow retroactive authorizations. However, obtaining prior authorization on the front-end before providing services increases the chance for prompt payment and decreases write-offs on the back-end. Some tips for getting prior authorization promptly are as follows.

  • If there is more than one location for your practice, centralize the responsibility for obtaining pre-certification in order to create greater efficiencies.
  • Seek blanket approval from carriers in case of a ‘plan-of-care’ for specific conditions and treatment protocols. This will minimize or avoid the need for calling every time for authorization.

    As the reimbursements from private and government carriers are on the decline, conduct an evaluation regarding how you manage your revenue cycle processes. This will give you a better understanding about the underlying issues affecting your bottom line and make you prepared to take necessary actions to improve your revenue cycle processes.

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