The best orthopedic billing company for your practice is one that can show results on surgical claims, global periods, workers’ comp and surgery center billing, with reports broken out by payer. Compare vendors on six points: ortho coding depth, denial rates, days in AR, workers’ comp handling, ASC experience and how long clients stay.
Why do most “top orthopedic billing company” lists look the same?
Search for the best orthopedic billing company and you will find page after page of “Top 10” lists. Read a few and a pattern shows up. Most are published by a billing company, and the company that wrote the list usually ranks itself first.
That doesn’t make the lists useless. They are a fair way to build a starting list of names. They just can’t tell you which company will do well with your payer mix, your surgeons and your surgery center. You find that out by asking every vendor the same questions and comparing the answers side by side.
This guide gives you those questions. It is written by Medical Healthcare Solutions, Inc. (MHS), an orthopedic and ASC billing company based in Andover, Massachusetts, so we have included ourselves at the end and invite you to hold us to the same standard.
What should you compare when choosing an orthopedic billing company?
Orthopedic billing has more moving parts than most specialties. A single surgery can involve a surgeon claim, an assistant claim, a facility claim, an implant invoice and months of post-op visits inside a global period. Use this table to compare vendors on the parts that matter most.
|
What to compare |
What to ask |
What a strong answer looks like |
|
Ortho coding depth |
How many certified coders work on orthopedic claims? |
Named coders with ortho experience, not a general pool |
|
Denial rate |
What is your denial rate for ortho clients, by reason? |
A number by payer and by denial reason, updated monthly |
|
Days in AR |
What are days in AR for your ortho clients? |
Standard and workers’ comp AR reported separately |
|
Workers’ comp |
How do you handle claim numbers, adjusters and state forms? |
A separate workflow and follow-up schedule for comp claims |
|
ASC billing |
Do you bill both the surgeon and the facility side? |
Years of ASC facility billing with references |
|
Client retention |
How long do your clients stay on average? |
A specific figure, backed by references you can call |
Two of these deserve extra attention. Modifier and bundling errors are a frequent cause of denied orthopedic surgical claims, because the payer’s edits decide which procedures can be billed together. CMS publishes these rules as the National Correct Coding Initiative (NCCI) edits and updates them every quarter. Ask how a vendor keeps up with those updates. Our guide to orthopedic modifier and bundling denials covers the common mistakes.
The second is global periods. Most major joint and spine procedures carry a 90-day global period, and visits inside it are only paid when the right modifier is used for an unrelated problem or a return to the operating room. CMS explains the rules in its Global Surgery Booklet. A billing company that gets this wrong either leaves money on the table or bills visits that should not be billed.
What types of orthopedic billing companies are there?
Most options fall into three groups. Each can be a good fit for some practices.
- Large national vendors. They handle high claim volume across many specialties. Pricing can be low. Ask who actually works your claims and whether you get a named contact who knows orthopedics.
- Software-first RCM companies. They lead with automation and dashboards. The tools can be strong. Ask how much of the denial follow-up is done by people, since complex ortho appeals still need a person on the phone with the payer.
- Specialty-focused billing firms. They concentrate on a small set of specialties such as orthopedics and surgery centers. Coders tend to know the procedures well. Ask for proof of results in a practice like yours.
Whichever group you look at, the questions in the table above still apply.
Which numbers should an orthopedic billing company report every month?
A good billing partner sends you a report you can understand in five minutes. At a minimum it should show:
- Clean claim rate. The share of claims accepted on first submission without errors.
- First-pass resolution rate. The share of claims paid on the first try.
- Denial rate by reason and by payer. So you can see whether the problem is coding, authorizations or eligibility.
- Days in AR, split by payer type. Workers’ comp and auto claims take longer, so they should be tracked on their own line.
- Net collection rate. What you collected out of what you could have collected.
If a vendor can only give you one summary number, that is a warning sign. You can’t fix what you can’t see.
What are the signs your current billing company is the wrong fit?
Most orthopedic practices don’t start shopping because of one bad month. They start because the same problems keep coming back. The common ones:
- AR keeps growing, and your billing company can’t explain why.
- Cash coming in doesn’t match how busy your surgeons are.
- Denials sit for weeks before anyone appeals them.
- Workers’ comp claims are lumped in with everything else.
- You only hear from your billing company when you call them.
If two or more of these sound familiar, it is worth getting a second opinion on your numbers. Our post on the orthopedic practice cash flow gap walks through where the missing money usually goes.
How does Medical Healthcare Solutions, Inc. (MHS) compare?
Here is how MHS answers the same six questions. These are our own figures, and we are happy to back each one with references.
- Experience: more than 30 years in healthcare revenue cycle management, including 20 years of ASC billing.
- Coding depth: more than 30 certified coders on staff.
- Surgery centers: billing support for more than 35 ambulatory surgery centers.
- Clean claim rate: 98.5%.
- First-pass resolution rate: 93.5%.
- Client retention: MHS clients stay an average of 14.5 years.
On results, one example is Orthopedic Specialists of Massachusetts. After moving its billing to MHS, the practice added about $113,000 a month in collections. Standard days in AR dropped from 36 to 29, workers’ comp days in AR fell from 58 to 46, and net collection rose from 92% to 97%. The full story is in the orthopedic practice case study.
You can read more about how we work on our orthopedic medical billing services page and on why practices choose MHS. If your group also owns a surgery center, our post on choosing an ASC billing company covers the facility side.
How do you check a billing company’s claims before you sign?
Every vendor will tell you they are good at orthopedics. Here is how to find out for yourself.
- Ask for two references from orthopedic practices that switched to them in the last two years, and call both.
- Ask for a sample monthly report with the names removed. Check that it shows denials by reason and AR by payer type.
- Ask for a review of your own data. A serious vendor will look at your current AR, denials and payer mix before giving you a price.
- Read the contract. Look at the term length, who works your old AR after a switch, who owns your data and what it takes to leave.
- Ask who your day-to-day contact will be and how fast they respond.
A vendor that can pass all five is worth a closer look, whatever list it appears on.
Frequently asked questions
What is the best orthopedic billing company?
The best orthopedic billing company is the one that can show results on claims like yours. Compare vendors on ortho coding depth, denial rate, days in AR, workers’ comp handling, ASC experience and client retention, and ask for references from orthopedic practices.
Are “top 10 orthopedic billing company” lists reliable?
They are a reasonable place to find names. Most are written by billing companies that rank themselves first, so check each vendor with your own questions and references before deciding.
What should an orthopedic billing company report each month?
At a minimum: clean claim rate, first-pass resolution rate, denial rate by reason and payer, days in AR split by payer type, and net collection rate.
How is orthopedic billing different from general medical billing?
Orthopedic billing involves surgical coding, 90-day global periods, modifier rules, implants, workers’ comp and auto claims, and often surgery center facility billing. Each adds steps where claims can be denied or underpaid.
Comparing billing companies right now? Start with a clear view of your own numbers. Get Pricing & Analysis and MHS will review your AR, denials and payer mix before you make a decision.
