Orthopedic Case Study
Orthopedic Case Study
How Orthopedic Groups Recovered $172K by Fixing Implant Billing and Surgical Claim Delays
Reclaiming Revenue in Orthopedic and Surgical Billing
When Surgical Precision Meets Back-End Blind Spots
Orthopedic surgery leaves no room for error. Every step in the OR is planned, executed, and documented with precision. But when it comes to billing, the discipline often breaks down.
In ambulatory surgery centers and orthopedic practices alike, procedures are done, implants are used, and yet the billing tells a different story, one riddled with omissions, delays, and denials. These weren’t the kind of mistakes that triggered alerts or got flagged in reports. They just slipped through, day after day, quietly chipping away at collections.
If your collections aren’t tracking with case volume, it’s not the volume that’s the issue. It’s what’s happening, or not happening, between surgery and submission. And that’s where losses begin.
The Real Cost of Missed Ortho Charges
Surgical teams are focused on the patient. That’s where their attention should be. But when billing teams don’t receive the right information at the right time, high-value charges fall through the cracks. Orthopedic billing is complex, filled with procedure codes, implant tracking, modifier use, and payer-specific requirements. A single point of failure can cause tens of thousands in lost revenue.
Here’s where it typically breaks down:
- Implant logs never sent to billing: Implants cost thousands, but if they aren’t documented and reconciled with the OR sheet and vendor log, they go unbilled.
- Operative notes incomplete or delayed: No op note, no claim. If surgical notes are held up or missing details, billing stalls or gets denied.
- Prior auths mismatched or missing: Without confirmed authorization for hardware and complex procedures, denials are guaranteed.
- Modifiers left off or used wrong: Whether it’s -50 for bilateral, -22 for complexity, or -LT/-RT for laterality, get one wrong, and the claim is rejected or underpaid.
- Late submissions past deadlines: A few days’ delay can turn into a total write-off when timely filing windows close.
One multi-location orthopedic group found that nearly 21% of surgeries had billing elements missing, costing an average of $720 per case. Over a quarter, that amounted to more than $180,000 in lost revenue.
How Scionis RCM Tackled the Problem
Orthopedic billing isn’t just about software. It’s about getting the right people to look at the right data, at the right time. Scionis RCM came in not to replace systems, but to fix what was being missed.
What We Focused On:
- Pre-surgical checks: Confirmed CPT-level prior authorizations tied to implants before surgery.
- Daily case reviews: Matched op notes, OR logs, and vendor implant sheets every 24 hours.
- Modifier audits: Specialty coders verified modifier accuracy before claims went out.
- Fast-tracked submissions: Clean claims sent out within 48 hours of surgery.
- Root cause denial tracking: Denials weren’t just fixed, they were analyzed and prevented.
This wasn’t a theory. It was a boots-on-the-ground engagement with a real orthopedic group that needed real results.
Case Study: Orthopedic Group Recovery in 90 Days
The Problem:
A 3-site orthopedic group with 12 surgeons had surgical volume on the rise but flat revenue. Billing delays, missing implant charges, and coding inconsistencies were dragging down collections.
Phase 1: Diagnostic Audit & Integration
- Audit of past 6 months: Over 18% of surgeries had implant charges missing.
- Billing lag: Claims took 5.2 days on average post-surgery.
- Denials: 1 in 3 denials were due to prior auth issues or modifier misuse.
Scionis RCM embedded coding leads and A/R analysts alongside their internal billing team. We walked their workflows, reviewed OR logs, and pulled reports no one had looked at in months.
Phase 2: Corrective Action Plan
- Daily implant reconciliation: Every surgery was cross-checked between EMR, vendor invoice, and OR sheet.
- Pre-auth mapping: Built a tracker that tied auths directly to scheduled cases and implant types.
- Specialty coders assigned: Claims scrubbed daily for proper CPT, ICD-10, and modifier accuracy.
- Dashboard roll-out: Real-time tracking by surgeon, site, and procedure with full transparency.
Denial prevention loop: All denials analyzed for patterns, then corrected at the root.
Results Within 12 Weeks:
- $172,000 recovered in missed revenue from prior quarters
- 33% drop in surgical claim denials
- Billing lag cut from 5.2 days to under 48 hours
- All surgical implant charges captured and submitted within the payer’s timely filing window
- Transparent dashboards shared weekly with clinical and billing leads
- HIPAA + GDPR compliance enforced on all shared documentation
- No software changes or staff increases required, only better coordination and smarter billing workflows
Orthopedic care requires precision. So does orthopedic billing. If your collections aren’t matching your surgical schedule, you don’t need more volume, you need to close the revenue gaps hiding in plain sight.
Scionis RCM doesn’t sell tools, we fix what others overlook. Let’s talk about the missing dollars in your surgical billing process, and how quickly we can get them back where they belong.
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