Gail S. Chorney, MD

Although not every orthopaedic surgeon needs to be an expert on the revenue cycle, it certainly helps to know a few basic concepts. The word “cycle” implies that the billing process may be just an endless circle with no payment in sight. However, if physicians and staff adhere to a few basic principles, it can be a straight line to the money.

Where it all begins
The revenue cycle begins when the patient calls the office to make an appointment. During that call, staff should ask for the patient’s insurance status and get enough information to validate that the coverage is active. Once the validity of that patient’s insurance is confirmed, staff should find out whether a referral from the patient’s primary care provider is necessary.

The staff person should also ask whether this is a workers’ compensation or no-fault insurance case. If so, the patient will need to provide additional data to confirm that this is an active case.

At the time of the visit, staff should review the patient’s demographic information. At follow-up visits, staff should confirm that the patient’s insurance has not changed due to a change in jobs or insurance providers. Any copayments or time-of-service payments should always be collected at the time of the visit.

Patient payments
Patients may be responsible for the following three types of payments:

• Copayment: Fixed amount payable by the patient for each visit
• Coinsurance: Fixed percentage of the contracted payment amount; for example, the insurance company may pay 80 percent of charges, leaving the patient responsible for the remaining 20 percent of charges
• Deductible: Amount of out-of-pocket expenses that must be incurred before the patient’s insurance kicks in

Under many plans today, patients may have both an in-network deductible and an out-of-network deductible. Some plans have deductibles as high as $10,000. Not collecting the patient’s deductible, therefore, may result in very little reimbursement for the physician.

The physician’s role
The physician’s main responsibility is to care for the patient. However, physicians must also be accountable for their role in the revenue cycle. Physicians should have a basic understanding of the various forms of patient health plans, such as health maintenance organizations (HMOs) and preferred provider organizations (PPOs). They must also understand that they have a contractual obligation to collect the payments that are the responsibility of the patient under those plans.

Physicians should not see HMO patients who do not have a referral on file because they will not get paid for the visit or be able to authorize possible diagnostic studies or treatment. The same is true for seeing out-of-network patients whose insurance does not include out-of-network benefits. A patient may elect to pay out of pocket for a second opinion but this should be clear at the time of the visit.

Never say “we will accept your insurance.” This may violate the contractual agreement with the insurer and may amount to accepting no reimbursement, if the patient has a very high deductible.

Physicians should also be aware of which common office procedures require preauthorization from the insurance company. For example, in orthopaedic surgery, injections of expensive medications usually require preauthorization.

Taking a coding course to understand both evaluation and management (E&M) coding and surgical coding may be helpful. A pattern of overcoding may result in an audit and a “clawback” of payments. The documentation of both office visits and surgery should support the coding, and office encounters and surgical charges should be submitted in a timely fashion.

Following these simple operating policies can improve a practice’s cash flow. With the shift to increasing patient responsibility for the cost of care, it is more important than ever to ensure collection of copayments, co-insurance, and deductibles from patients and to bill and submit charges to insurers on a timely basis.

Gail S. Chorney, MD, is a member of the AAOS Practice Management Committee. She can be reached at gail.chorney@nyumc.org

Additional Information:
To learn about requirements issued by the U.S. Centers for Medicare & Medicaid Services (CMS) and The Joint Commission regarding medical scribes, consult the following online resources:

The Joint Commission FAQ: Use of Unlicensed Persons Acting as Scribes

CMS.gov FAQ’s