Most billing company pitches sound the same. They guarantee improved collections, reduced denials, and seamless handoff. What they don’t tell you is if their team can manage a knee arthroscopy with a same day injection, a fracture with a 90-day global or a worker’s compensation case that takes two years.
They guarantee improved collections, reduced denials, and seamless handoff. What they don’t tell you is if their team can manage a knee arthroscopy with a same day injection, a fracture with a 90-day global or a worker’s compensation case that takes two years.
How many orthopedic practices do you bill for right now?
Start here. A company that bills for a few dozen orthopedic groups will have seen your payer problems before. If it is a company that primarily provides family medicine and is “also” offering ortho, they are learning on your money. Request numbers, and inquire if the individual assigned to your account has had experience with orthopedic claims?
Who handles global periods and modifiers?
Orthopedic revenue is a silent leak at surgical global periods. Post-op visits within a 90-day global are not billable; a new problem, return to the OR a staged procedure is billable. That is where modifiers like 57, 58, 78, 79, and 25 come in. Inquire about how the team decides which modifier is to be used, if the coders read the operative note or if they only work off the charge sheet. If it is general, they will say “no”.
How do you handle implants, DME, and bracing?
Orthopedic practices have costs which are not shared by most specialties. Correct coding for implants, bracing, walking boots, or other durable medical equipment requires both payer rules and correct coding. Find out who monitors these, how they are invoiced and if the company knows what the actual payers pay for. If practices don’t ask this question, then they will discover they have been incurring supply costs.
Can you manage workers’ compensation and personal injury cases?
A lot of orthopedic patients come in with an accident or through the workplace. These cases are not billed normally by the commercial bill. Workers’ comp is based on fee schedules and state-specific rules while personal injury may be based on liens that only pay if the case settles. Either this is the biller’s obliviousness to the deadline or it’s the biller that has forgotten to collect some money that was meant to be collected. If you have this type of patient, then this is a deal breaker question.
What does your prior authorization process look like?
Advanced imaging, injections and surgeries are often required to be approved before their performance. Inquire who gets the authorizations, how far in advance they begin, and what is done when someone does not get an authorization. Ask also if that is a part of the fee or additional. If the authorization was never in place, there is no possible way to create a clean claim.
Do you actually specialize, or do you just list orthopedics?
You don’t just want a company that provides orthopedic medical billing services, you want a company that specializes in it. The best way to find out is by asking some questions. How to code shoulder arthroscopy for multiple procedures? What edits do you look for when you have 20610 and 20611 injections? What is your experience with bilateral procedures and multiple procedure reductions? Quick response from a real expert who doesn’t read from a script.
What reports will I see, and how often?
Ask to see a sample report before you sign. You should be able to access your first pass acceptance rate, denial rate from various payers, by reason, days in AR and collections against charges. The smallest period for which this is possible is monthly. Be wary of a vendor who refuses to provide actual numbers or claims that the reports are “customized later.
What are the full costs and the contract terms?
Most companies charge a percentage of collections, commonly in the range of 4% to 8%, though some use flat or per-claim pricing. What matters is what is included. Ask about setup fees, credentialing, patient statements, and any add-ons. Then read the contract for the term, the notice period, and what happens to your data and open claims if you leave. A fair contract lets you exit if performance drops. A hard one locks you in for years.
What happens when something goes wrong?
Every practice has a bad month. A payer changes a policy, a code gets updated, a batch of claims is rejected. What you want to know is who picks up the phone, how quickly they respond, and whether there is one named person or a support queue. Ask how they communicate about denial trends and how they would flag a problem before it turns into a cash flow issue.
Putting the answers to use
Once you have talked to two or three companies, compare the answers side by side. Pay less attention to who promises the biggest improvement and more to who answers your specific questions with specific detail. A company that knows your specialty will bring up problems you hadn’t asked about, which is usually a good sign.
The bottom line
Changing billing companies is a true commitment and should be given a proper interview. Follow the questions here to beat the sales pitch and to obtain the information in writing and select a partner who understands what occurs from the exam room to the payment. This is where the money is made and lost in the orthopedic business.