Challenges faced by Solo Orthopedic Practitioner’s

Running an independent orthopedic practice can be both fulfilling and financially rewarding. 

While orthopedic care is crucial to addressing musculoskeletal issues, the pressures of managing both clinical and business operations can feel overwhelming for solo practitioners in orthopedic medical billing. 

“As per the American Academy of Orthopaedic Surgeons, the study states that about 12% of orthopedics have private practices, while others operate as part of larger healthcare systems or in collaboration with other medical groups.”

However, orthopedic surgeons and practice managers often face significant challenges in keeping their practices profitable while managing administrative demands. 

At the core of these difficulties is the issue of effective Revenue Cycle Management (RCM). 

For any practitioner, proper orthopedic medical billing is essential to maintain profitability, minimize losses, and ensure smooth operations of RCM.

Our experts at EZ Settle Solution will address key areas where solo orthopedic practices face challenges, their pain points, and their impact on businesses. 

1. Heavy Administrative Burden

For most solo orthopedic practitioners, handling administrative tasks is a major challenge. Beyond treating patients, you’re responsible for appointment scheduling, medical billing, coding, handling patient records, and ensuring compliance with ever-changing healthcare regulations. Each task takes valuable time away from patient care and adds to the stress of running the practice.

Without sufficient administrative support, practitioners often find themselves bogged down by paperwork, managing insurance claims (orthopedic medical billing), and dealing with coding errors – all of which can lead to missed revenue opportunities and inefficiencies in practice management.

2. Orthopedic-Specific Expertise: The Key to Accurate Orthopedic medical billing

Orthopedic practices often need help with specialized medical coding and billing, leading to costly errors and lost revenue. Orthopedic medical billing requires precise coding for both surgical and non-surgical procedures, which general billing teams may not fully understand.

• Why Coding Expertise Matters in orthopedic medical billing

Orthopedic coding requires a deep understanding of the specialty to accurately describe the procedures performed. This is especially important for newer or advanced techniques like Principal Care Management (PCM), which general billing teams may not fully understand. Staying up to date with coding requirements and having a team that knows the details of orthopedic-specific coding is essential for orthopedic medical billing to get paid for the work you do.

• Managing Authorizations and Reducing Denials

Another challenge for orthopedic practices is managing pre-authorizations. Mistakes or delays in paperwork can result in services being denied or postponed because the necessary pre-authorizations weren’t completed. These delays not only disrupt patient care but also lead to last-minute cancellations, adding more financial strain to your practice.

“A survey conducted by the American Medical Association found that it takes healthcare providers about 16 hours per week to obtain prior authorizations. In orthopedic practices, this number even reaches 30 hours.”

To avoid this, it’s crucial to have accurate and timely documentation. Proper management of authorizations not only helps prevent denials but also keeps patients happy by reducing unexpected delays in their care.

3. Adapting to Changing Payer Rules

Orthopedic practices face challenges when dealing with payers, both nationally and locally. Payers often update their rules, which can lead to claim denials, lower payments, and confusion around reimbursement. Practices that don’t keep up with these changes may lose money due to incorrectly coded claims or not meeting new payer guidelines.

• National Payer Challenges

National payers frequently change their requirements for submitting claims, making it hard for smaller practices to keep up. This can result in claims being paid at lower rates than expected. To avoid this, it’s important to have a team that regularly reviews these changes and adjusts billing practices to ensure maximum reimbursement.

• Importance of Local Payer Knowledge

Local payers also have specific policies that can be tricky to navigate. Large revenue cycle management (RCM) companies may overlook these, but understanding local payer rules is crucial for independent practices. Building strong relationships with local payers helps ensure that claims are processed smoothly and paid in full.

For Solo orthopedic practices, having a partner like EZ Settle Solution who understands both national and local payer rules and manages your orthopedic medical billing is key to optimizing reimbursements.

4. The Complexity of Orthopedic Medical Coding

Orthopedic procedures require precise and accurate coding to ensure smooth processing of insurance claims. However, orthopedic medical coding is particularly complex, involving specialized codes that, if mishandled, can result in rejected claims, payment delays, or reduced reimbursements.

For solo practitioners without dedicated billing and coding teams, keeping up with coding updates can be overwhelming, impacting the financial health of the practice.

• Challenges in Orthopedic Medical Coding

Like all healthcare sectors, orthopedics faces constant coding challenges. The current ICD-10 system in the U.S. is set to be replaced by ICD-11 by 2025. Coders will need to adapt to these updates quickly. Even with ICD-10, accuracy in using codes and modifiers is critical to avoid overcharging or undercharging, which can lead to claim rejections.

Here are a few examples of common coding Errors in Orthopedics Medical Billing

• Bundling Errors: For example, Evaluation & Management (EM) services are not billable separately when an injection is performed on the same day unless a distinct diagnosis with a modifier is used.
• NCCI Edits: Using the right modifiers with NCCI edits is essential. For instance, a 59 modifier can be applied when billing 20553 (trigger point injection) along with 20610 but cannot be used with 64461 (Introduction/Injection of Anesthetic Agent – Nerve Block)
• Medical Necessity: Claims for procedures like facet joint injections (64492 and 64495) require thorough documentation of medical necessity, or they may only be covered upon appeal.
• Therapy Codes: Physical therapy codes need GP or GO modifiers. Services exceeding the Medicare cap require a KX modifier with documentation.
• Non-Payable Codes: Codes such as 97010 (hot/cold packs) and 99080 (miscellaneous services) are not reimbursable by Medicare or commercial plans.

Proper coding and billing are critical for orthopedic medical billing to avoid financial losses and keep revenue cycles healthy.

5. Finding a Trusted RCM Partner for Orthopedic Medical Billing: A Key to Long-Term Success

One of the most important decisions a solo orthopedic practitioner or independent practice owner can make is selecting the right RCM partner. The complexities of orthopedic medical billing and coding, along with the challenges of dealing with both national and local payers, require an experienced partner who is invested in the success of your practice.

“Did you know that the average claims denial rate across most hospitals in the United States is between 6 and 13%?”

Now your claim denial rate depends on your decision to choose an RCM partner. 

Choosing the right RCM partner can reduce this rate by up to 50%.

Wrap-up

Solo orthopedic practices face unique challenges, from complex orthopedic medical coding and payer dynamics to the need for data transparency and strong partnerships. 

But you don’t have to tackle these challenges alone.

EZ Settle Solution offers specialized orthopedic medical coding, expert knowledge of payer systems, and a data-driven RCM approach to help maximize your revenue by handling orthopedic medical billing and reducing administrative burdens.

Ready to improve your Orthopedic medical billing?

Contact EZ Settle Solution today and let us handle the complexities so you can focus on delivering exceptional patient care.

Talk to our RCM Experts to receive a Free Assessment at 346-335-4093 / info@ezsettlesolutions.com