By using this site, you agree to the Privacy Policy and Terms of Use.
Accept
Health Works CollectiveHealth Works CollectiveHealth Works Collective
  • Health
    • Mental Health
    Health
    Healthcare organizations are operating on slimmer profit margins than ever. One report in August showed that they are even lower than the beginning of the…
    Show More
    Top News
    HIPPA compliance
    How Medical Office Staff Can Make Your Practice HIPAA Compliant
    October 29, 2021
    Everything you need to know about hyaluronic acid treatment
    Everything you need to know about hyaluronic acid treatment
    February 10, 2022
    Which Mushroom Capsules Are Good for Your Health?
    May 5, 2022
    Latest News
    Why Custom Telemedicine Apps Outperform Off‑the‑Shelf Solutions
    July 20, 2025
    How Probate Planning Shapes the Future of Your Estate and Family Care
    July 17, 2025
    Beyond Nutrition: Everyday Foods That Support Whole-Body Health
    June 15, 2025
    The Wide-Ranging Benefits of Magnesium Supplements
    June 11, 2025
  • Policy and Law
    • Global Healthcare
    • Medical Ethics
    Policy and Law
    Get the latest updates about Insurance policies and Laws in the Healthcare industry for different geographical locations.
    Show More
    Top News
    Image
    Healthcare Pricing Transparency Gains Momentum
    June 24, 2013
    non-clinical care factors in health outcomes
    Addressing Non-Clinical Care Factors in Health Outcomes
    November 15, 2013
    e interventions
    Healthcare Progress Depends On “E Interventions”
    July 10, 2014
    Latest News
    How IT and Marketing Teams Can Collaborate to Protect Patient Trust
    July 17, 2025
    How Health Choices and Legal Actions Intersect After an Injury
    July 17, 2025
    How communities and healthcare providers can address slip and fall injuries with legal awareness
    July 17, 2025
    Let Your Lawyer Handle the Work Before You Pay Medical Costs
    July 6, 2025
  • Medical Innovations
  • News
  • Wellness
  • Tech
Search
© 2023 HealthWorks Collective. All Rights Reserved.
Reading: Orthopedic Revenue Cycle Management: Two Major Concerns (and How to Fix Them)
Share
Notification Show More
Font ResizerAa
Health Works CollectiveHealth Works Collective
Font ResizerAa
Search
Follow US
  • About
  • Contact
  • Privacy
© 2023 HealthWorks Collective. All Rights Reserved.
Health Works Collective > Business > Finance > Orthopedic Revenue Cycle Management: Two Major Concerns (and How to Fix Them)
BusinessFinanceHospital AdministrationOrthopaedics

Orthopedic Revenue Cycle Management: Two Major Concerns (and How to Fix Them)

Andy Salmen
Andy Salmen
Share
6 Min Read
Image
SHARE

ImageAs anybody involved with revenue management will attest to, revenue cycle management is a crucial element for a physician office operation. Ensuring smooth revenue management processes ensures a well-focused, effective, efficient practice.

ImageAs anybody involved with revenue management will attest to, revenue cycle management is a crucial element for a physician office operation. Ensuring smooth revenue management processes ensures a well-focused, effective, efficient practice.

There are several concerns that may create problems and issues for a practice.  Reevaluating your practice’s orthopedic revenue cycle management for potential problems is the best way to avoid them.  Here are two chief concerns a practice can face and how to fix them.

Managing Insurance Denials – OR “Why aren’t these claims getting paid?”

More Read

Physician Marketing, Online Marketing, LinkedIn
5 Ways LinkedIn Helps Physicians in Marketing Their Practice
8 Months Until ICD-10 Implementation: What to Know
The Art of Engagement: A Review
Little Things Do Make a Big Difference: Globalizing Personal Health
Healthbox Nashville Launches with 7 Fresh Digital Health Startups

One of the biggest problems, and the one that accounts for a large portion of reimbursement problems, is that of claim denials.  Claims resubmissions following a denial are time consuming and a real pain for most practices.  The most common reason for insurance denial is incomplete or inaccurate insurance information.  The days when procedures were remunerated in high volumes and individual insurance denials could be overlooked or ignored are in the past.  These days it is far too costly to simply overlook insurance denials.

Often, insurance carriers do not want to pay claims if they don’t have to and look for reasons to deny them.  If there are three errors on a claim it will likely be denied three times.  The first time an error is encountered the claim will be denied.  If that error is corrected and the claim is resubmitted it will be denied again when the next error is encountered, and so on.  This is why it is so important to submit clean claims and why claim scrubbing is such an essential part of the submission process.

Take the time and steps necessary to minimize insurance denial problems: 

  • Develop and implement initial processes designed to ensure improved results by providing accurate information to the insurance providers.
  • Create a system of patient eligibility verification that ensures each patient has proper coverage for the procedures being performed.  The process should begin as soon as the patient is scheduled for a procedure.
  • Seek pre-authorization prior to the procedure.  Retroactive authorization is no longer accepted.  Any procedure not pre-authorized is essentially “free.”
  • Assure that the requirements of “medical necessity” are being met.
  • Make sure that there is a claim scrubbing process in place.

Denials are a reality and a constant one.  What you do with the information provided by the payor regarding the denial can make all the difference.  Take the information provided and make an action plan to make positive changes:

  • Identify monthly denial volumes and organize by type i.e. coding, front end, medical necessity, need more information, etc.
  • Trend those types retrospectively to identify if issues are systemic and consistent or a one-time anomaly.
  • With this data, create an action plan to fix preventable denials (front-end, authorization, coding, etc.) and put in place management protocols to handle appeals. 

Tracking Reimbursements – OR “Am I getting properly reimbursed from the insurance companies?”

Regardless of how big or important insurance companies are, they are still run by humans who make mistakes.    Sometimes these mistakes are in the form of a simple entry error on a given claim.  Other times the mistakes take the form of improper updating of reimbursement rates for a whole class of patients.  For example, not incorporating a “carve out” for your Worker’s Compensation patients means that the work comp claims are paid at the PPO rate instead of the WC rate.

It is essential to have a data sheet with reimbursement rates for each procedure for each different plan and for each different insurance carrier.  Having this set up in your Practice Management system for an automated comparison of actual reimbursements to contracted rates would be optimal, but lacking that, a periodic paper-based audit should be employed. 

Most practice management systems do have this automated functionality, however, we have found it is often incomplete in its functionality and at times inaccurate in its comparisons as adjustments are often auto-calculated as well.  With this we often employ separate technology in addition to the practice management system to ensure our client’s are being paid their contracted amount.

HIS discovered several examples where underpayments to practices were in the $100,000 range. There was an instance when the insurance company updated their technology; they loaded the incorrect fee schedule from a different year.  This would have lead to significant loss to our client if we were not tracking those payments. Since 2010 alone, we effectively recovered $2.5 million in underpaid reimbursements for our clients.

A thorough, efficient audit system that incorporates comparisons of every payment received and negotiated rates will help to keep things in order.

Image: olovedog/Freedigitalphotos.net

Share This Article
Facebook Copy Link Print
Share

Stay Connected

1.5kFollowersLike
4.5kFollowersFollow
2.8kFollowersPin
136kSubscribersSubscribe

Latest News

botox certification
Help Improve People’s Skin Health Via Botox Certification
Skin Specialties
July 22, 2025
Telemedicine Apps
Why Custom Telemedicine Apps Outperform Off‑the‑Shelf Solutions
Health
July 20, 2025
Grounded Healing: A Natural Ally for Sustainable Healthcare Systems
How IT and Marketing Teams Can Collaborate to Protect Patient Trust
Global Healthcare Policy & Law
July 17, 2025
paramedics in surgical gloves and masks
How Health Choices and Legal Actions Intersect After an Injury
Health care
July 16, 2025

You Might also Like

Maintain Interest, Create a Buzz: Simply Update Your Website!

September 8, 2014
BusinesseHealthHealth ReformHospital AdministrationMedical EducationMobile HealthPublic HealthWellness

Cliff Diving for Healthcare Innovation

January 6, 2013

How to Deal With Online Patient Complaints

March 19, 2012
health administration
BusinessFinanceHospital Administration

Hospital Boards Grapple with Uncertain Future: What to Do Now?

May 18, 2014
Subscribe
Subscribe to our newsletter to get our newest articles instantly!
Follow US
© 2008-2025 HealthWorks Collective. All Rights Reserved.
  • About
  • Contact
  • Privacy
Welcome Back!

Sign in to your account

Username or Email Address
Password

Lost your password?