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Orthopedic Group in Nevada

Overview

  • Privately held Orthopedic group in Nevada
  • Specialty: Orthopedic (Joint Replacement, Spine Care, Pain Management, Physical Therapy, Open MRI, Trauma Fracture Care, Upper Extremity Surgery, Sports Medicine, Etc.)
  • Over 50-years of history of providing the highest quality orthopedic services for patients throughout Nevada
  • Clients’ Revenue per year > $20M (2020)

Implementation

  • Daily claims submission
  • Quarterly coding audits and constant auditing of coding by in-house CPC coders
  • Weekly discussions with front staff to review Prior Authorization Denials
  • Improved payment turnaround time through proper eligibility checks and escalation of un-insured patients prior to the appointment date
  • Fix denials within 48 hours
  • Follow up date based collection follow ups and daily follow up on denials
  • Aggressive follow up on claims passed 150 days from Date of Service
  • Real-time Analytics reports (DOCTRIX®)
  • Weekly progress reports
  • Monthly Revenue analysis report
  • Quarterly Onsite Strategy Discussions
  • Quarterly Discussions with Providers
  • Best Practices recommendations

Challenges

  • An average of a 12-day delay in surgery claim submission
  • Non-specific coding and lack of documentation (Non-compliant coding related to E & M, Bundling issues)
  • Not Securing Prior Authorization for required services resulting in loss of revenue
  • Increased eligibility related denials
  • Increased denials related to Physical Therapy Cases
  • Lower first time payment rate
  • Higher zero pay CPT%
  • Poor transparency to overall and individual performance of providers

Result

  • Billing turnaround time improved from 7 to 4 days
  • Seamless transition to new improved Practice Management System helping with the coding and documentation challenges
  • Reduction in the 90+ Insurance AR from 40% to 15%
  • Reduction in the Days in AR from 49 Days to 25 Days
  • Clean Claim rates improved to 99%
  • Consistently maintained Zero pay claims at less than 2%
  • Resolved claim % at 90 and 120 days is 99%
  • 100% transparency into RCM processes
  • Best in class & compliant business processes

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