When Orthopedic Practices Should Outsource Billing
Orthopedic billing requires dual expertise in high-volume office visit processing and complex surgical claim management. Few in-house billing teams have both capabilities. A biller who handles office visits efficiently may lack the training to code multi-procedure surgical cases, manage global periods, and track implant billing. Outsourcing becomes attractive when surgical claim denial rates exceed 8%, when operative reports are not translated into claims within 72 hours, or when the practice is losing revenue to global period billing errors.
Criteria 1: Surgical Billing Expertise
The billing company must have demonstrated orthopedic surgical billing experience. Ask for their surgical claim denial rate, average time from operative report to claim submission, and their process for handling multi-procedure surgical cases with modifier 51, 59, and bilateral modifiers. Request examples of how they code common orthopedic procedures: total knee arthroplasty, ACL reconstruction, and fracture ORIF with hardware placement.
Criteria 2: Global Period Management
Ask how the billing company tracks 90-day surgical global periods. They should have an automated system that flags surgical patients and prevents routine post-op visit charges during the global window. Ask about their process for billing unrelated E/M visits (modifier 24) and returns to the OR (modifier 78) during the global period. Manual tracking of global periods breaks down in practices with 30+ surgical cases per month.
Criteria 3: Authorization Management
Orthopedic surgical authorization is time-sensitive and high-stakes. The billing company should handle the authorization process end-to-end: submitting the request with clinical documentation, tracking status, communicating approval or denial, and managing peer-to-peer reviews when initial authorization is denied. Ask for their authorization approval rate and average turnaround time.
Criteria 4: Pricing for Mixed Claims
Orthopedic billing pricing should account for the mix of simple office visits and complex surgical claims. Percentage-based pricing (6% to 8% of collections) works well because it automatically adjusts for the higher revenue per surgical claim. Per-claim pricing ($5 to $10 per claim) may undercharge for surgical claims and overcharge for office visits. Some companies use tiered pricing: one rate for E/M claims and a higher rate for surgical claims.
Criteria 5: Implant and Supply Billing
For practices operating in outpatient surgical centers or ambulatory surgery centers, the billing company must manage implant billing using HCPCS codes. This includes tracking implant inventory, matching implant invoices to surgical cases, and billing the appropriate HCPCS code for each device. Missing implant charges is a significant revenue leak in orthopedic surgery billing.
Red Flags
Avoid billing companies that do not have existing orthopedic surgical clients. Surgical billing requires specific expertise that cannot be learned on your account. Also avoid companies that cannot explain the difference between modifier 51 (multiple procedures), modifier 59 (distinct procedural service), and modifier 78 (return to OR during global period). These modifiers are fundamental to orthopedic billing.