Expediting the Collection Process for a Leading Ortho Client Through Accurate & Timely Claims Submissions

Maintaining positive revenue cycles has a direct impact on the cash flow and solvency of the healthcare service providers. In the age of digital transformation, the traditional models of billing, coding and claims submissions do not work well today as they cause inaccuracies, unnecessary delays and higher claims denials. In the past few years, revenue cycle management (RCM) has come to occupy a central place in the healthcare industry as effective RCM strategies and practices not only affect the liquidity and solvency of the healthcare practice, but also patient care and experiences. 

Technological advancements and innovative solutions from third-party RCM service providers have enabled healthcare providers to maintain positive revenue cycles with minimum delays and inaccuracies while freeing up staff time and effort to enable them to focus on providing quality care and experiences to an increasing flow of patients.  

Background 

Orthopedics is a fast-growing field within the healthcare industry. Two main reasons for the accelerated growth of the field are the aging population and rapidly growing innovations in treatment 

Atom Healthcare’s client, a leading ortho player with __ physicians and over __ patients, was facing delays in the claim submissions and resultant delays in collections. The submission process also had inaccuracies and variances but without a robust RCM plan, their cash flow and revenue cycle were disrupted. This deterred them from handling the growing volume of ortho patients. 

  • Processes Supported
  • System Environment
    • Practice Management System
    • Document management/EMR
    • Any other supporting systems

Orthopedics RCM: A brief background

Orthopedic medical billing, coding and revenue cycle management are as specialized and complicated as the field itself. Orthopedics covers a large number of procedures, surgeries, rehabilitation, etc. A typical ortho treatment plan involves multiple procedures, rehabilitation, etc. and even surgeries may consist of multiple surgeries and procedures in one. Such complexity and need for specialized billing, coding and RCM knowledge and skills cause orthopedic practices to have higher inaccuracies in billing, higher instances of under-coding and high volume of incorrect claims submissions and denials. The result – underpayment, higher denial rates, drop in revenues and negative cash flows for orthopedics practices. 

Despite the increasing demand for orthopedic services, higher numbers of patients and larger volumes of treatments offered, orthopedic practices may still suffer from negative cash flows and a fall in revenues owing to inaccurate, delayed or improper claims submissions. For a flourishing orthopedic practice, a consistent flow of revenue made possible by effective RCM practices and strategies is indispensable. 

Challenges

The client was finding it challenging to make accurate and timely claims submissions which were affecting their cash flows. 

  • There were discrepancies and mismatches in the records of and information updated by appointment provider and rendering provider.  
  • This led to the accumulation of the pending claims as the claims were not being submitted to the payers in a timely manner after the service. 
  • The filing time after the service shot up to more than 5 days.  
  • This led to incessant delays in claim collection and affected their revenues. 

Our solutions

Having understood and analyzed the client’s core challenges, Atom Healthcare crafted a detailed strategic plan to enable the client to reduce submission delays and inaccuracies, ensure quick account collection for improved cash flow and escalation processes for variances and denials. The plan included the following elements. 

  • Educating the provider’s office: The staff at the provider’s office were provided in-depth and holistic training on various aspects of orthopedic EMR/EHR, need for accuracy in medical billing and timely submission. The staff at the provider’s office were trained and equipped to update the correct rendering provider’s name in the medical records in a timely manner. 
  • Setting up of Escalation process: By setting up an escalation process for variances and claims denials, the client was enabled to expedite the appeals process through appropriate appeals to the payer. 

Results

With scalable and standardized processes, in-depth training to the provider’s office staff and effective planning, Atom Healthcare enabled this ortho client to make the claims process seamless and effective. Our team enabled the practice to accomplish the following. 

  • Accurate information capture: The provider’s office started updating the correct information about the treatment provided by the rendering provider in the EMR/EHR.  
  • Expedited claims submission: The provider’s office has been submitting all the claims within 48 hours without any delay. There are pending claims or backlogs after the service has been rendered.
  • Enhanced collection: The practice has been able to meet the collection within the stipulated time period. With the escalation process for denials and variances in place, the quantum and speed of claim collection has improved for the client. 

Overall, the ortho client has been able to maintain positive cash flows and enhance revenues alongside the rise in the number of patients and the volume of treatments.

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