Top 10 Strategies to Maximize Collections for Sports Medicine
Being a team physician is a great opportunity for independent orthopedic providers to support local schools and professional teams, contributing to the community while keeping athletes healthy and able to perform. Sports medicine specialists also help keep patients active and exercising throughout their lives, providing valuable surgical and non-surgical treatment options.
But too often, providers are not paid quickly or fairly for this work because of the complexities of this subspecialty when it comes to reimbursement.
How can independent orthopedic providers be sure to maximize their chances of collecting in full for the valuable services provided by sports medicine specialists?
Read on for Orthos’s Top 10 strategies for maximizing collections based on our experience supporting orthopedic groups and facilities as a revenue cycle partner.
10. Know thy trainer
Athletic trainers play a crucial role not only in delivering treatment, but facilitating the flow of crucial information like insurance coverage for players as well as commitments that the school may make to cover any out of pocket costs. Having these clear lines of communication and policies in place ahead of time can help prevent thorny situations down the line where the provider is left holding the bag. Revenue cycle teams can be prepared if and when a patient needs urgent help.
9. Get retro auths when you have to call an audible
Intraoperative findings in sports medicine procedures are common given the limitations of preoperative imaging and nature of the work. But authorizations for insurance are based on the codes you thought you would do in the original treatment plan, and if you end up doing different codes you will need to get retro authorizations if you can. Unfortunately by the time the coders get your operative report it may be too late. Many payors require notification the same day or the next day to consider a retro.
8. Don’t get kneecapped by Aetna
Aetna medical policies (almost uniquely among payors) make reimbursement for meniscectomies very difficult. Many sports medicine providers end up doing 29880 and 29881s for free because Aetna considers them experimental except for acute tears. In most other situations dealing with medical necessity, this is identified during the authorization process, but these are “no auth” codes for Aetna. Orthopedic billing teams, watch out!
7. Call your shot
Be sure the operative plan is reflected on your order to the greatest extent possible. “Rotator cuff repair and other indicated procedures” is a recipe for claim denials and lost revenue. Many providers rely on the EMR to translate “words into numbers” but this can be unreliable or out of date. Best practice is to write out in your office note and surgical order the full surgical plan so that your authorization team, facility, device rep, and everyone else is on the same page from the start.
6. You gotta fight…for your right…to see out of state Medicaid
Especially at the collegiate level, your practice may be exposed to unfamiliar insurance companies for out of state athletes who may still be on their parents insurance or not on the school’s plan. Out of state Medicaid can be particularly tricky and these cases will require additional time to be sure you can get paid according to the home plan’s regulations. Sometimes what’s best for the patient will be to go home to have the procedure. But in cases where out of state providers are allowed, you will need to have your ducks in a row up front.
5. Notes, or it didn’t happen
The days of simply stating “patient failed conservative treatment” as a justification for needed procedures are long gone. Not only are payors requiring dates that physical therapy was performed, they are increasingly asking for the notes themselves, even if the therapy was not done in-house. Patients may need to help track these notes down from other providers, and be sure these are always in the chart when they are available. Medical billing and RCM teams can always ask if they are needed, but by that time you are risking delays to treatment while they are found.
4. Don’t take that (multiple procedure) penalty stroke
Many sports medicine cases are subject to “multiple procedure discounts” in payor contracts that say they will pay the primary procedure at full price, but only 50% or some share of the rest of the procedures. Your reimbursement team should be responsible for knowing these regulations and checking to make sure they are not being abused. Some payors who are not entitled to take these discounts in their contracts may try to get away with it anyway (cough, workers comp, cough.) RCM teams need to have the analytical capabilities to make these reimbursement checks easy and automated.
3. Keep your (coding) head on a swivel
Coding for sports medicine procedures is evolving significantly. Codes are being added, removed, and changed to add-on or standalone every year with updated CPT guidelines. Be sure your coding team is taking advantage of professional development. And if you are coding your own orders or surgeries, be sure that you are staying up to date as well. Subacromial decompression (29826) is one of the most difficult procedures to get reimbursed these days, and documentation can make the difference.
2. Don’t make it a coin toss
Many times when athletes are injured, there are several parties potentially taking financial responsibility. The school, the parents, the student, another financial supporter. Ultimately it feels like you’ll be covered but written documentation is essential up front to be able to justify the claims on the back end. It’s also important to know who needs to see the claim first. All of this can be sorted out in advance, and with the help of the administrator of the health plan. Better not to leave responsibility up to chance.
Pull in the same direction
As with many other aspects of maximizing revenue cycle performance and collections, it really is a team effort. From the front desk and registration, to clinical documentation, to coding and billing, to authorizations, to the facility, everyone has a part to play. Sports medicine can often be the subspecialty that pulls everyone together and ensures communication is optimized and processes are working as they should be given some of the particular complexities you face.