Optimizing Orthopedic Billing: 7 Tips for Faster Payments and Fewer Denials

Orthopedic surgeons are experts at navigating complex structures like the inside of a knee or shoulder. But even with these skills, navigating the complexities of the medical billing process can be a challenge.

While providers want to focus on caring for patients and managing their practices — rather than focus on coding procedures and submitting claims — orthopedic surgery involves some unique factors that can make billing even more complicated.

However, understanding the orthopedic billing process and learning how to navigate it efficiently can benefit your practice. It can help ensure timely reimbursements, enabling you to cover the costs of doing business, like buying supplies and paying your staff. It also means you get paid for the services you provide.¹

In addition, improving your healthcare billing process can provide a more positive payment experience for your patients, help patients move forward with recommended treatments and boost patient satisfaction.¹

Read on to learn more about how you can optimize the billing process for your orthopedic surgery practice.

1. Check Prior Authorization

It’s common for insurance companies to require prior authorization for complex treatments and procedures, including many performed by orthopedic surgeons. This prior authorization process can be time-consuming and can sometimes lead to delays in care.²

Keep these delays to a minimum by checking patient insurance information and streamlining your process for completing prior authorizations before any procedures. For returning patients, don’t forget to update personal information and confirm that there haven’t been any changes to their insurance coverage.

2. Provide Detailed Documentation

Orthopedic procedures involve a wide range of body parts, often including multiple components within an individual joint. They may also involve specialized techniques, overlapping treatments and the use of a variety of medical devices and implants.³

To minimize errors and denials in healthcare billing, it’s important to carefully and thoroughly document every step before, during and after a procedure.⁴ Be sure to note specific details, such as the exact bone or joint being treated, all the techniques used in the procedure and any devices implanted.

3. Stay Current With Coding

Medical coding involves assigning a specific alphanumeric code to track every diagnosis and service being paid for.

Orthopedic coding, in particular, has a high degree of specificity — there are different medical codes for an arthroplasty, for example, depending on the included procedures.³ This is where your careful documentation of the procedure comes into play because it helps staff accurately code the treatments you’re billing for.

Even with careful documentation, however, coding errors can happen. Medical codes for orthopedic procedures are updated frequently, so invest in training and make sure staff are up to date on all current codes.

Improper bundling or unbundling of services can also be an issue in orthopedic procedures because they often involve multiple bones or parts of a joint and a variety of treatment modalities. Bundling or unbundling services incorrectly can result in a claim being denied, so be sure to familiarize yourself with the payer’s rules so that procedures can be coded properly.⁵

4. Take Special Care With Evaluation and Management Services

Orthopedic practices can sometimes face additional challenges in getting reimbursed for certain evaluation and management (E/M) services. This can become an issue when a provider records E/M on the same day as a previously scheduled treatment or service.

As an example, imagine a case where an orthopedic surgeon conducted an initial evaluation of a patient and created a treatment plan that involved a series of joint injections scheduled at regular intervals. The provider may wish to conduct a follow-up evaluation midway through the series to determine if the injections are helping the patient. While this evaluation may be medically necessary, if it is performed on the same day as a previously scheduled injection, it may be rejected.

In these cases, proper documentation is key. If additional E/M is needed, be sure to carefully document the service as well as its medical necessity to help prevent inappropriate denials.

5. Cover Your Bases With Claims Submission

Coding errors are the second most common reason for the denial of claims.¹ But claims can also be denied for many other reasons, like failure to obtain pre-authorization or failure to file a claim within the payer’s deadline.⁶

Taking the time to confirm you’re using the correct form, filling out the form completely and double-checking that the itemized claims are listed accurately can help reduce inappropriate denials and speed up reimbursement. Make sure you include any necessary documentation and submit the claim on time.

Once the claim is submitted, continue to follow up regularly to check on its status, so you can respond quickly if there is a denial.

6. File Timely Appeals

If a claim is denied, read the insurer’s explanation carefully to understand why. Improper denials aren’t just a cost of doing business — they’re mistakes that need to be corrected. So if you think a claim was denied inappropriately, file an appeal with the insurer.

Using an appeals template can make this process easier and more efficient. Provide any additional information or documentation that may be needed, and continue to follow up on the appeal to ensure timely processing and payment.

7. Make It Easy for Patients to Pay

Even when everything goes well and insurers pay what’s expected, you will typically also need to collect payment from the patient for their portion of the bill. You can improve the patient payment experience with some of these tips:⁷

• Provide cost transparency by offering estimates and price lists before the procedure.

• Consolidate bills within your healthcare system or practice when you're able to.

• Make it easier for patients to pay by offering a variety of payment options, which should include digital payment methods.

Finally, if a patient is struggling to pay for services, look for ways to help them make it work. Offer a variety of options and solutions, like accepting multiple forms of payment, financing options or payment plans. This can help remove barriers to patients accessing care they need or want, while also helping to reduce the chance of nonpayment.

The Value of Better Orthopedic Billing

Improving your orthopedic billing process can help streamline operations, reduce denials and ensure timely reimbursements for your practice. By focusing on accurate documentation, up-to-date coding and efficient claims management, you can minimize errors and improve financial stability. Taking proactive steps in these areas can enhance your billing practices as well as the patient experience, making high-quality orthopedic care more accessible.

A Patient Financing Solution for Health and Wellness Providers

If you are looking for a way to connect your patients with flexible financing that empowers them to pay for the care they want and need, consider offering CareCredit as a financing solution. CareCredit allows cardholders to pay for out-of-pocket health and wellness expenses over time while helping enhance the payments process for your practice or business.

When you accept CareCredit, patients can see if they prequalify with no impact to their score, and those who apply, if approved, can take advantage of special financing on qualifying purchases.* Additionally, your practice or business will be paid directly within two business days.

Learn more about the CareCredit credit card as a patient financing solution or start the provider enrollment process by filling out this form.

Author Bio

Ilima Loomis is a freelance writer with more than 18 years of experience in journalism and B2B content marketing. With a background in writing about science and technology, she has a knack for taking on complex subjects and helping readers understand not only what is going on but why it relates to them. She specializes in writing about healthcare, health tech and medical research.

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