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Common Obstacles in Orthopaedic Billing That Undermine Revenue Generation

A medical billing administrator

Common Obstacles in Orthopaedic Billing That Undermine Revenue Generation

Orthopaedic practice revenue relies on accurate and timely revenue cycle management (RCM). However, correctly coding and billing for orthopaedic services rendered can be complex, even for the most experienced billing teams. From deciphering complex coding rules to keeping pace with new regulatory and billing requirements, orthopaedic billing teams face countless barriers to revenue at each step in the revenue cycle.

The Top 5 Obstacles to Orthopaedic Revenue Growth

In order to submit clean claims and receive timely payments, orthopaedic billing departments must tackle these five hurdles:

1. Reimbursement Pressures: One of the primary challenges facing orthopaedic practices is navigating the complex world of healthcare reimbursement. With constant changes in reimbursement models, declining reimbursements from payers, and increasing administrative burdens, practices often find themselves struggling to optimize revenue streams. Implementing efficient billing and coding processes, staying updated on reimbursement policies, and negotiating favorable contracts with payers are crucial steps to mitigate reimbursement pressures.

2. Complex regulatory requirements. Updates to regulatory policies can easily derail an orthopaedic billing office. Staying on top of changes to Medicare policies, ICD-10 code revisions, and new value-based care models is crucial to ensure reimbursements and avoid policy violations. Failure to comply with these regulatory changes can lead to non-compliance penalties, reimbursement delays, and possibly legal ramifications. However, recognizing and implementing these changes consumes significant time and resources, which can be especially challenging for smaller practices.

3. Prior authorization and pre-certification. Securing prior authorizations and pre-certifications for certain procedures is a time-consuming and cumbersome process, requiring billing teams to be proactive about future billing needs. While these authorizations are routine functions, collecting the level of documentation and medical justification necessary for approval can quickly create bottlenecks in practice workflow. Moreover, back-and-forth communication with payers can also create major delays, leading to postponed procedures and patient dissatisfaction. Denials originating from a lack of prior authorization can be challenging to rework, creating an overload in the billing office and a deficit in practice revenue.

4. Denial management. Denials are a frustrating reality for orthopaedic practices — some are ultimately out of your control. That’s why prompt and effective denial management is crucial for a healthy revenue cycle. Many practices struggle with high denial rates due to common errors and workflow oversights, including lack of eligibility verification, coding errors, insufficient documentation, and missed submission deadlines. Without a structured approach to tracking, analyzing, and correcting the root causes of denials, practices will continue to see poor financial performance as their rejected claims work against the bottom line,

5. Legacy A/R. Managing accounts receivable (A/R) is a challenge for nearly every orthopaedic practice — especially accounts that have been aging for several months or longer. Over time, uncollected balances from older accounts accumulate, creating a compounding impact on cash flow that drains revenue each month. Most billing teams just don’t have the time, staff, or resources to efficiently follow up on outstanding claims — and the longer a claim sits in A/R, the less likely your practice is to get paid.

Outsourcing RCM: The Revenue-Saving Move for Orthopaedic Practices

The challenges associated with in-house RCM can quickly drain practice resources and overburden staff, creating a ripple effect of inefficiencies that impact clinical care and patient satisfaction. With an outsourced partner like Med USA, you can tackle each of these hurdles in your billing office to ensure steady cash flow and efficient practice operations. Med USA’s orthopaedic billing solutions leverage an expert team of RCM specialists and business intelligence-powered analytics to help your practice keep up with critical billing changes, submit clean claims, reduce A/R, and minimize denials. With Med USA, your orthopaedic practice can build a more profitable, scalable, and compliant revenue cycle that increases practice revenue by an average of 18%.

Ready to Learn More About How Outsourcing Orthopaedic RCM Can Improve Your Financial Performance?

Talk to a Med USA representative today!