RCM for Orthopedic Practices

Denials and rejections are essential to ensuring a strong revenue cycle management. This is an area that can be potentially neglected simply because of a lack of dedicated resources, particularly in smaller offices.

As Dave pointed out earlier, one of the things that we track very closely are rejections and denials to determine the cause. We typically find that the number one reason for a claim to be rejected is typically it is human resource related. Either the person at the front desk or the person assigned the responsibility of getting the information from the patient does not get all of the information needed and/or it is entered incorrectly into the information system, which causes that initial rejection.

We typically find if you have an employee at the front desk who is responsible for checking-in, checking-out patients and doing patient registration you’re typically going to find a higher degree of errors than if the registration process is delegated to someone who is not multitasking. Training of the front office staff on the process of those insurance cards is very important.

Daily rejection percentages should be single digit.

  • Ask your staff, “are we current with the management of our rejections and denials?”
  • More importantly, make sure they know what the percentage of denials is and what causes the denials. This is important for accountability and tracking purposes.
  • Have your staff show you the trends.

There are many companies out there that through your clearinghouse can install scrubbing software and add it to your practice management system. Essentially that software will act as the bridge between your organization and the clearinghouse. It will look at and determine if you have a proper diagnosis along with services and that those are properly linked together. It will, in some instances, flag and say that you’re missing something or that there are inconsistencies.

Once again, you get a rejection within an hour of submission of a claim, but you get a denial upwards of six weeks after submission. Our intention is to obviously avoid both, but if you are to get them, get the rejections. This allows us to make edits and then train the staff so that less rejections occur. Further, your clearinghouse also has the ability to allow and give you edits and rejections coming back. If you take anything away from today it’s trend it, understand it, and then fix it so that it doesn’t reoccur.

Lastly, there is plenty of software available at a low cost to be able to do eligibility validation and verification. We often find that without that occurring it increases the number of rejections related to the processing of the claim.