Prosthetic billing outsourcing is a fairly common practice among healthcare providers, orthopedics, and DME vendors. The basic reason is the inability of internal staff to handle the typical billing of prosthetics and orthotics. Often subject to a copay and/or coinsurance, orthotics and prosthetics coverage has different requirements for various devices and varies by payer. This must come within the member’s benefit provisions. A prosthetics biller has a lot to do. That includes:
• Pick up the prescription from the ordering doctor dated before the delivery date.
• Consider the limitations of the covered item based on the fixed time period. Example: Medicare covers one pair of orthopedic shoes per calendar year.
• Invoice appropriate modifiers.
• Consult letter of medical necessity and additional documentation required for some devices. Example: PPR form for prosthetic devices.
• Check the coverage of devices subject to qualifying diagnosis.
• Consider repair or replace and supply for separate reimbursement based on eligibility.
Most providers, orthopedics, and durable medical equipment companies see their billing staff spend a lot of time offsetting these rather time-consuming and burdensome operations, already fraught with various responsibilities. Add to this in-depth knowledge of Medicare, Medicaid and commercial plan reimbursement guidelines, your warning, etc. necessary to perform these jobs expertly. Operational inefficiency in these areas directly impacts cash flow as claims denials increase and accounts receivable collection suffers. This is why you should consider outsourcing prosthetic billing.
Prosthetic Billing Outsourcing: How It Helps
A trusted medical billing service offering prosthetics (and orthotics) billing solutions will provide you with a number of features including:
Eligibility Verification
• Check the active Policy for a date of service
• Check the copay/coinsurance/OOP, Rx and Dx entry
• Verify provider status
• Check the authorization requirement
• Get authorization
authorization check
• Follow up until resolution and closure
• Complete the authorization process efficiently
• Monitoring p periodically to maintain the validity of the authorization
medical coding
• Coding based on place of service: inpatient and outpatient coding
• Coding based on provider specialty: E/M, cardiology, orthopedics, physical medicine, etc.
• Assign appropriate ICD-10 codes for diagnosis
• Assign modifiers as appropriate
• Code review and quality control
• Communication with the physician’s office for any additional medical documentation and clarification required
Analysis of accounts receivable
Analysis of accounts receivable
follow up with payment
Closing of claims
Denial management
• Correction of claims
• Forwards
• Patient responsibility
However, you should be very careful to find a billing partner who can take care of your prosthetic billing needs within your budget and provide you with a comprehensive practice management/revenue cycle management solution.