Prosthetic billing outsourcing: why it matters

2019-05-16 Business No comment

Prosthetic billing outsourcing is very common among healthcare providers, orthopedics and DME sellers. The basic reason is that internal employees cannot handle the typicality of prosthetic and orthotic billing. Often subject to deductible and/or co-insurance, orthotics and prosthetic coverage require different requirements for various devices and vary from payer to payer. This should be a member's welfare clause. Prosthetic journalists have a lot to do. That includes:

• Collect prescriptions from the ordering doctor before the delivery date.


• Consider the limitations of the covered projects based on a fixed time period. Example: Medicare covers a pair of corrective shoes every year.


• Bill's appropriate modifier.


• Check medical necessities and other documents as required by certain equipment. Example: PPR form of a prosthetic device.


• Check the coverage of equipment that is eligible for diagnosis.


• Repair or replace and provide separate reimbursement based on eligibility.

Most health care providers, orthopaedic surgeons, and DME companies believe that their billing staff spends a lot of time fighting these operations, which are time consuming and burdensome because they are already full of responsibilities. Coupled with an in-depth understanding of the reimbursement guidelines for Medicare, Medicaid and Business Plans, they need the warnings they need to perform these tasks professionally. The inefficient operation of these areas directly affects cash flow, as claims are denied and receivables are hit. This is why you need to consider prosthetic billing outsourcing.

Prosthetic billing outsourcing: how it helps

A reliable medical billing service that provides a prosthetic [and orthotic] billing solution will provide you with a range of features including:

Qualification verification

• Check if the policy is the service date


• Check co-payment / co-insurance / OOP, Rx and Dx entries


• Check provider status


• Check authorization requirements



Authorization verification

• Follow-up until resolution and closure


• Efficient completion of the authorization process


• Follow up regularly to maintain authorization effectiveness

Medical code

• Service-based coding location: inpatient and outpatient code


• Provider professional coding: E ​​/ M, cardiology, orthopedics, physical medicine, etc.


• Assign the appropriate ICD-10 code to the diagnosis


• Specify modifiers as needed


• Code review and quality assurance


• Communicate with the physician's office to obtain any additional medical documentation and necessary instructions

A / R analysis

Analyze A / R.

Follow up payer

Close claim

Refuse management

• Claim correction




• Patient responsibility

However, you need to be very careful looking for billing partners who can handle prosthetic billing needs within budget and provide you with an end-to-end revenue cycle management/practice management solution.

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