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Billing Total Joint Replacements

31 Oct 2016, Posted by Terry Coleman in Billing, Healthcare, Revenue Management
executive-briefing

Total joint replacements are among the most common procedures in America—more than 1,000,000 of these surgeries are performed every year. Historically, total joints have been a hospital staple. But as demand for these procedures grows, and as medical technologies continue to advance, many physicians have opted to move total joints into ambulatory surgical centers (ASCs), where patients encounter lower risk of infection, more affordable costs and vastly superior outcomes.

In response, many ASCs have developed specialty programs for outpatient total joints (OTJ), and they’ve proved advantageous for the centers as well as their payors and patients.

If your ASC is planning to implement outpatient total joints, take a moment to consider how contracting, billing and revenue cycle management can optimize your performance.

Stay On Top: Payor Contracts & Negotiations

While most payors don’t classify total joint replacements as an outpatient procedure, they have been quick to notice the potential for savings and, as a result, have started entering into custom contracts with ASCs. With this in mind, ASCs can leverage their knowledge of insurance policies and cost data to improve payor contract negotiations. Here are three strategies to keep in mind:

  1. Make sure medical policies for your OTJ program are pulled from insurance carriers so you’re sure to meet their criteria.
  2. Employ carve-outs for the total joint implants so your center doesn’t lose money on the procedure.
  3. Think outside OTJ and consider all procedures you can and may want to perform at your center—you set yourself up for success when you negotiate contracts ahead of time.

Monitor the Process: Streamline Coding, Billing & Communications

To develop a profitable OTJ program, ASC leaders must streamline all aspects of program communication and billing; this includes making sure the right codes are documented and bills are paid in full. Once again, we offer three key ideas for staying on top of the process:

  1. Consider a nurse navigator. This person works with insurance verification to ensure approval before surgery and educates the patient on their financial responsibility.
  2. Monitor coding teams to ensure they are capturing the correct codes and maximizing contracts with implant carve-outs.
  3. Work with a third-party billing agency to monitor reimbursement and consider partnering with a local health system for contract negotiations.

Consider Bundled Payment Programs

Bundled payment programs are growing rapidly in popularity and are uniquely suited to OTJ procedures. Bundled payment rates are often much easier for patients to manage, particularly for those who are self-pay or self-funded employers, because they roll all fees into a single, flat rate. In most cases, bundled payments cover the entire episode of care, from initial consultation to 90 days (or more) post-op.

The movement toward OTJ programs is an opportunity for ASCs to expand their service lines and improve revenue streams. At the same time, these programs offer total joint patients a streamlined experience that results in lower costs and improved outcomes.

So consider the possibilities for your ASC, and talk to in2itive Business Solutions about optimizing your performance from the beginning.

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