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Critical Role of Insurance Verification Process in Orthopedic Practices
Critical Role of Insurance
Verification Process in Orthopedic
Call: 1-800-670-2809 www.outsourcestrategies.com
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.
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
If you require detailed information, call the insurance company
representative instead of browsing the website or relying on an
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
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
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Main: (800) 670 2809
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About Outsource Strategies International
Outsource Strategies International (OSI) is a reputable medical
outsourcing solutions provider based in Tulsa, Oklahoma offering
advanced medical billing and coding solutions for hospitals,
physicians, physicians' groups, clinics and other healthcare entities.
Find more details at: www.outsourcestrategies.com.