Evolent’s Post

The Prior Authorization Process is Broken! Now imagine you have a grade 1 L4-5 spondylolisthesis. After years of nonoperative treatment, you see a surgeon who recommends surgery. The surgeon completes a prior authorization of the proposed procedure which your health insurance carrier approves with the caveat, 'prior authorization is no guarantee of payment.' The surgeon performs the procedure as stated with great results. You are genuinely surprised to find out at a post-op appointment that your insurance carrier denied your surgeon payment.  The surgeon's business office then begins the process of filing appeal after appeal over the next several months and ultimately writes off the balance. Thus, the surgeon performed the surgery for free on someone with commercial insurance. This scenario happens in 1 out of 10 spine surgeries. Denial of payment after prior authorization has become a grim reality of American healthcare. #priorauth #physicians #spine

I'm a little late to the party but life has been fairly hectic lately and I wasn't able to view the Four Corners Investigation myself and have only now just been able to read through the article Very insightful and valuable information! Great job to the researchers and journalists behind it and so rewarding to see one of our own Orthopaedic Surgeons Prof Ian Harris was able to provide his perspective on the topic. A lot of the Orthopaedic Medical Negligence cases that come across our desk are often due to the surgeon performing surgeries that aren't particularly necessary when taking into account whether it will help alleviate their pain, or cause more distress. This investigation can help shed some light on why this seems to be the case. in case you missed it I would definitely recommend giving it a read. #medicolegal #medicolegalprovider #medicolegalassessmentsgroup #medicalnegligence #medicalnews #personalinjurylaw #personalinjury #personalinjuryclaim #personalinjuryclaims #legal #lawfirm #surgery #orthopaedicsurgery #spinalsurgery #billing #businessdevelopment

Biggest problems facing ASCs today.....Nothing new. The cost of performing surgery continues to rise, while insurance reimbursements have not. Post-pandemic costs have had a significant rise, coupled with an overall decrease in revenue overall. The growing competition presented by hospitals and ASC systems.

Why is the Australian Private Hospitals Association (APHA) challenging Private Healthcare Australia's (PHA) claims about increases in out-of-pocket costs? With 60% of elective surgical procedures occurring in the private #health sector... https://lnkd.in/gj-fbU7j #healthcare #surgery #privatehealthcare #medtech #medicaldevices

Hospital care accounts for 31% of all health care costs in the US, with a quarter of those procedures classified as inappropriate. This is why self-funded plans must take meaningful action to ensure plan members undergo procedures only when needed. Our self-guided Welvie My Surgery® program teaches members how to explore other options with their doctors to make informed treatment decisions. Check out this article to learn more about rising health care costs: https://hubs.ly/Q020s83W0 #surgery #employeebenefits #healthliteracy #healthcare #costcontainment

THE MUSCULOSKELETOVERSE: I know this a bit cheeky but let me explain. MSK care represents anywhere between 23-38% of total US healthcare spend yet remains highly fragmented and siloed, with entry often dependent on their health insurance plan. We expect primary care physicians to be the Walmart of healthcare, and demand that they do so with Gucci or Prada level quality. It has always seemed to me to be a mismatch. I believe that my primary colleagues do an amazing job but could never globally match the expectations they are held to and required to meet. In MSK, a patient enters care much like a pinball enters a pinball machine. They might see a PCP, physical therapist, chiropractor, podiatrist, rheumatologist, primary care sports medicine physician, physiatrist, pain medicine, and/or orthopaedic surgeons. The care that patient receives could be highly dependent on whichever bumper they hit first in the pinball analogy. It might end in a great outcome, but frankly we don’t routinely measure those outcomes. So, imagine a multidisciplinary musculoskeletal health practice where all these equity-holding specialists focused on patient health, outcomes, and value delivery. If excess value in that delivery exists, that value is shared by those in the front line of patient care. I believe we must move past what has worked for us for so many years, stand-alone specialty practices. That approach has led approximately 65-70% to be employed by others. We are working on a different model that will insure sustainability of our independent practices. With all respect to Marvel and DC Comics, this is my vision of the musculoskeletoverse. It doesn’t require superheroes, only groups of physicians and aligned specialists focused on trust, collaboration, and improving patient care and outcomes.

#MedicalBilling #OrthopedicServices #CodingGuidelines #Documentation #Modifiers #MedicalNecessity #TimelyFiling #FeeSchedule #PreAuthorization #AppealsProcess Here are some guidelines for successful medical billing in orthopedic services: 1. Ensure accurate coding of diagnoses and procedures using CPT and ICD codes. #CodingGuidelines 2. Complete and accurate documentation is crucial for billing purposes. Include detailed information about procedures performed, diagnosis, treatment plans, and patient data. #Documentation 3. Use modifiers appropriately to indicate any alterations to services or procedures rendered (e.g., multiple occurrences, bilateral procedures, different provider). #Modifiers 4. Ensure that all billed services are medically necessary and supported by proper documentation in the patient's medical record. #MedicalNecessity 5. Submit claims within the designated timeframe specified by insurance carriers to avoid claim denials due to late filing.  #TimelyFiling 6. Familiarize yourself with fee schedules for the orthopedic services you provide as reimbursement rates may vary among different insurance carriers.  #FeeSchedule 7. Obtain pre-authorization from insurance companies for orthopedic procedures that require it to prevent claim denials.       #=PreAuthorization  8.Appeal denied claims by following the appeals process outlined by insurance companies and providing additional supporting documentation.               9.Stay updated on changes in billing regulations, coding guidelines, and insurance policies affecting orthopedic medical billing practices.           #=StayUpdated  10.Improve documentation practices continuously to accurately capture the complexity of services provided for appropriate reimbursement.                  11.Utilize coding software or EHR systems with built-in coding assistance features to enhance accuracy and compliance with billing guidelines.         12.Ensure that all providers involved in orthopedic medical billing are properly credentialed with relevant insurance companies.#Credentialing 13.Provide ongoing training and education for staff involved in the billing process to ensure understanding of coding guidelines, documentation requirements, and proper billing procedures.#TrainingAndEducation Remember consulting with specialists or experts experienced in orthopedic medical billing can provide valuable insights into regional specific regulations. Healthcare providers who are interested in obtaining medical billing services can reach out for more information via email at hayesalvis66@gmail.com or by phone at +923075648959. #MedicalBilling #HealthcareFinance #RevenueCycleManagement #ClaimSubmission #HealthcareBilling #InsuranceClaims #MedicalCoding #PatientBilling #HealthcareReimbursement

After a long negotiation (11 months) with Orlando Health insurance program, OHWLBSI has been able to stablish the new guidelines for weightloss surgery. What a great victory for the team members https://lnkd.in/eZdVRfiu The ASMBS/IFSO Guidelines now recommend metabolic and bariatric surgery for individuals with a BMI of 35 or more “regardless of presence, absence, or severity of obesity-related conditions” and that it be considered for people with a BMI 30-34.9 and metabolic disease and in “appropriately selected children and adolescents.” But even without metabolic disease, the guidelines say weight-loss surgery should be considered starting at BMI 30 for people who do not achieve substantial or durable weight loss or obesity disease-related improvement using nonsurgical methods. It was also recommended that obesity definitions using standard BMI thresholds be adjusted by population and that Asian individuals consider weight-loss surgery beginning at BMI 27.5

Great stuff. This is also the same info I share with patients on: 1. How to decrease your risk of getting primary osteoarthritis, degenerative meniscus tears and chronic tendinosis 2. How to decrease the need for the joint replacement if you’ve already been diagnosed with early or mild osteoarthritis. #orthopedics #lifestylemedicne #OLM #movementortho #movementislife

Finally, a practical guide to #TotalKneeAnthroscopy from one of the world's top orthopedic surgeons!