Billing for orthotic services and procedures may seem like a straightforward affair at apparent sight. But in reality, it entails complications that no orthotics specialist, who is serious about getting paid in the end, can afford to ignore. Let’s take a closer look at how things pan out when it comes to orthotics billing. It is an area that is fraught with challenges. Payers are on their toes to deny claims at the slightest drop of the hat. Providers need to exercise extra caution to ensure that every claim submitted to the patient’s insurance plan is complete, spotless, and carries all the details that the payer wants.
This brings us to another problem.
How far can a typical orthotic practice really go to ensure that all the boxes are checked? Especially, when they have to do with their existing setup and staff?
The risk of overburdening the team always looms large in such circumstances. Efficiency in orthotics billing cannot be imposed by force on an inadept team. Nor can it be achieved without proper preparation and a close familiarity with payer rules and reimbursement caveats.
There is, however, a solution that works to improve workflows, mitigate challenges, and keep your existing team untaxed. Before discussing it, let’s try to understand some common challenges in orthotics billing.
Common Challenges Faced in Orthotics Billing
The most notorious culprit responsible for causing billing hiccups is incorrect or incomplete documentation. Healthcare claims hinge heavily on documentation, or accurate documentation, to be precise. Orthotics claims often get denied because the accompanying documentation doesn’t clearly prove the medical necessity, or describe the procedure in adequate details. Missing physician notes, weak diagnoses, or a poor linkage between evaluation, prescription, and device delivery can trigger denials, especially from Medicare and large commercial payers.
Such challenges can be addressed by using standardized documentation checklists aligned with each payer, ensuring that physician notes explicitly justify why the service was required, aligning diagnosis codes with the procedure, and conducting pre-submission audits before the claims are submitted to the payer.
More Challenges (and Solutions)
Another important area where orthotists often falter is coding. Orthotics billing demands the correct use of HCPCS codes and modifiers. It relies heavily on HCPCS L-codes, which are highly specific in nature. Some of the common issues faced in this regard include:
- Selecting the wrong L-codes
- Applying incorrect modifiers (LT/RT, KX, GA, etc.)
- Billing custom devices as off-the-shelf items (or vice versa)
To mitigate these problems, providers should use an updated L-code master list, and employ certified coders experienced in DMEPOS and orthotics.
Difficulties with billing for orthotic supplies do not stop here. A major challenge lies in securing prior authorization. Many orthotics require prior authorization, and coverage rules vary drastically by payer. Missing PA, or submitting it late, can lead to automatic denials, even when the device is medically necessary.
Finally, there are issues related to the proof of delivery (POD) and receipt issues. These are a frequent reason for post-payment audits and recoupments.
Finally, a Solution that Works!
The challenges mentioned above are not exhaustive. One might say that they are just the tip of the iceberg. If one actually gets down to sum them all up, the result may seem overwhelming. So, is there a way out?
Yes. And the easiest solution is enlisting external professional help.
In a practical scenario, upgrading your existing team of billers, coders and other RCM personnel may seem like an uphill task. It will entail finding and recruiting new people, imparting training, upgrading workflows, procuring new office space and equipment to accommodate the expanded team, and so on. However, all of the above can be instantly bypassed by outsourcing orthotics billing to a dedicated orthotics billing company that specializes in this field.
Delegating billing affairs to a third-party medical billing service provider not only streamlines your reimbursements from payers, but also helps you save on operational cost. Some of the best names in the market today operate on a price point that is surprisingly affordable and highly sustainable. And their services come with all the extras that you wish you had in your own internal setup, like trained and certified professionals, streamlined workflows, regular audits and stringent quality checks, and a pricing model that is strictly based on hours actually worked.
Outsourcing orthotics billing services is not a novelty any more, nor a luxury. It has emerged in recent times as a crucial measure for staying afloat in the healthcare industry with its rising cost, labor shortage, and ever-growing payer complexities. It has become a strategic move for orthotic practices who wish to improve collections without having to go through all the usual hassles of upgrading their existing back-end team.
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