Introduction
In healthcare, Orthotics and Prosthetics (O&P) play a crucial role as they help patients with musculoskeletal and neurological impairments to enhance their quality of life. The O&P devices help regain or improve the patient’s mobility and functionality. However, billing for Orthotics and Prosthetic devices can be complicated and time-consuming. One of the biggest challenges in O&P billing is ensuring proper reimbursement and timely claim processing, which is often disrupted due to a lack of eligibility and benefits verification. By confirming the patient’s coverage details and benefits beforehand, Orthotics and Prosthetics providers can avoid denials, delays, and inaccuracies frequently occurring in billing.
In this blog, we’ll explore why eligibility and benefits verification are essential for Orthotics and Prosthetics practices and how they can optimize the billing process and improve the revenue cycle.
Understanding Orthotics & Prosthetics Billing
Prostheses (artificial legs and hands) and orthoses (braces and splints) help people with physical impairments or functional limitations to live a healthy, productive, independent, and dignified life and to participate in any activities just like others in society. Using orthotics and prosthetics can decrease the need for formal healthcare, support services, long-term care, and caregivers. Without access to these O&P devices, people who need them are often excluded and isolated, which enhances the burden of mobility and disability. The billing for O&P devices can be challenging due to varying insurance coverage, changing payer-specific regulations, incorrect patient information, or non-compliance. These challenges include the risk of claim rejections, resulting in delayed reimbursements.
The Role of Eligibility & Benefits Verification
Eligibility and Benefits verification is verifying a patient’s information before the services are rendered. With accurate eligibility and benefits verification, patients experience fewer issues with claim denials, leading to enhanced patient satisfaction as they can access healthcare services without any financial roadblocks. This is a key component in healthcare revenue cycle management as it ensures providers receive proper reimbursement for the services rendered. Eligibility and Benefits Verification can be executed by contacting the insurance provider manually or electronically. Besides this, many healthcare institutions utilize real-time eligibility (RTE), an automated system that can instantly verify a patient’s insurance coverage and benefits.
Key Steps in Eligibility & Benefits Verification Process in O&P Billing
Eligibility and Benefits Verification process is a crucial step in the Revenue Cycle Management process. Besides human error, claims are often denied due to outdated or incorrect insurance verification, which makes this process crucial in O&P billing. The key steps within the eligibility and benefits verification process include:
- Obtaining patient demographic information (name, date of birth, address, insurance provider, etc.)
- Adding patient’s insurance information into the EHR and PM tool
- Verifying patient’s insurance information electronically by selecting the appropriate benefit and service type
- Identifying information from the eligibility checklist (policyholder, policy effective date & term date, patient copay, coinsurance, deductible, etc.)
- Determining whether the services are in-network or out-of-network benefits
- Verifying if the recommended services require any pre-authorization
- Following up with the patient to seek any missing or incorrect information
Challenges in Eligibility & Benefits Verification in Orthotics and Prosthetics Billing
Here are some key challenges of insurance eligibility verification facing O&P providers today:
- Inaccurate Patient Information
Accurate and comprehensive patient data should be acquired to verify patient information for providing Orthotics and Prosthetics devices. However, one of the biggest challenges facing O&P providers is getting reliable patient data. Inaccurate patient information, which usually results from human errors and outdated data, may result in delayed payments and denied claims.
- Complex Insurance Policies
Another major obstacle in Orthotics and Prosthetics billing is understanding and navigating the intricacies of different insurance plans and coverage regulations. It may be challenging to comprehend the specific needs of each insurance plan, which might have a wide range of coverage restrictions, exclusions, and variations.
- Dealing with Multiple Insurance Providers
For various reasons, some patients have multiple active health insurance policies. One policy acts as a primary policy, while the other is a secondary policy. To ensure accurate billing, the in-house billing staff must ask about any secondary coverage during the insurance verification. Juggling multiple insurance policies can be time-consuming and prone to error, resulting in failed eligibility checks and denied claims.
- Unclear Communication
Transparency in provider-patient communication is fundamental to verifying coverage, ensuring payment receipts, and fostering strong patient-provider relationships. Unclear communication or a lack of transparency can not only undermine trust between a patient and a provider but also directly impact delayed claims processing. Communicating with payers can also be challenging due to long wait times and limited accessibility.
Best Practices for Eligibility & Benefits Verification in O&P Billing
- The in-house billing staff needs to gather accurate demographic and insurance information about patients upfront at the time of registration. Furthermore, utilizing electronic health records (EHR) and integrating them with insurance databases can help validate insurance information, streamline the verification process, and minimize errors.
- To address policy changes and coverage guidelines, it is crucial to provide ongoing training and education to in-house billing staff about insurance verification. Corresponding with insurance companies, establishing clear communication lines, and utilizing online resources can clarify policy details and resolve uncertainties.
- Confirming coverage for both primary and secondary payers is crucial. The medical billing team must also carefully identify which insurance policy needs to be billed. This can minimize duplicate claim submissions and enhance the clean claim submission rate.
- Establishing clear communication between payers and providers is essential. It can help resolve claim inquiries, clarify coding or documentation issues, negotiate fair reimbursement rates, and improve patient satisfaction.
- Hiring a specialized billing company with years of industry experience in O&P Billing will allow practices access to expertise and knowledge, ensuring their claims are submitted without error.
Conclusion
Orthotics and Prosthetics billing is a time-consuming process that requires physicians to dedicate ample time to getting reimbursement for the devices rendered. However, as a specialized niche area, Orthotics and prosthetics billing requires billers to understand the orthotics and prosthetics items; otherwise, claims can be denied. Hiring a specialized billing company can be the best practice, among others, to simplify the billing process and minimize errors.
