Surgical practices operate on tight margins, and every denied claim, delayed reimbursement, or coding error chips away at revenue that should already be in the bank. One of the biggest challenges you might have is that if things are slowing down, you are getting denials, or your front desk is working more on chasing payments than on scheduling patients, it may not be your surgeons or your staff. It’s your billing colleague.
Many general surgery practices believe that billing problems are an inevitable part of practice. They’re not. Aside from the fact that it will slowly cost you thousands of dollars per month, most practices don’t realize how much it is until they compare to another billing company or get a fresh pair of eyes.
The Hidden Cost of a Weak Billing Partner
Surgical billing isn’t anything like that of a primary care appointment. Multiple CPT codes, modifiers, global periods and payer-specific rules apply to a single procedure and may vary depending on whether the procedure is performed during an inpatient, outpatient or ambulatory surgical center visit. If there is no complete understanding of these details within the billing team, errors occur, and these errors manifest themselves and end up in underpayments, denials, or even in claims that are abandoned.
Some of the indications you may be having that your billing company may be leaving money on the table are:
Understandably, with no progress being made, denials are on the rise, and claims are languishing in accounts receivable for up to three months, as coding mistakes creep into the system due to global surgical periods, modifiers and bundling.
Not one of these is a minor inconvenience. They are all real dollars that should be in your practice’s bank account.
Why General Surgery Billing Requires Specialized Expertise
General surgery coding is so complex that billing teams that juggle multiple specialties often end up getting lost. For instance, if you have a global surgical package, you’re getting reimbursed for pre-op, intra-op and post-op care provided in one package — and you don’t want to guess what is included versus what can be billed separately.
Include the number of times these modifiers are used in staged procedures, unrelated post-op services, or return visits to the OR and it’s easy to see why generalist billing companies can’t keep up. A team that specializes in family medicine or internal medicine is just not prepared to spot all the details of a surgical case and that can cost a lot of money.
That is why the surgical practice should have a general surgery billing company that understands and breathes this specialty and not one that takes it for granted.
What to Demand from a Surgery Billing Partner?
If you’re evaluating your current billing relationship or shopping for a new one, hold your partner to a higher standard.
Here’s what should be non-negotiable:
Specialty-Specific Coding Knowledge
Your billing team needs to have surgical coding inside and out, ranging from global periods, bundling rules, and the modifiers that only apply to surgical claims. If they are not fluent in their answers to the question about what is different in billing between a laparoscopy and open surgery, that is a red flag.
Proactive Denial Management
Don’t simply re-file denials and forget about them. A good billing partner not only monitors denials, but determines the reasons for the denials and makes changes to processes so that the same problem doesn’t happen again and again every month.
Transparent Reporting
It should never be a question of what is going on with your revenue cycle. Basic requirements are real-time dashboards, monthly performance reports, and communication regarding aging claims.
Credentialing Support
Payer credentialing delays can be a serious problem that can slow down the surgeon’s patient care before she even sees her first patient under a new contract. A good billing partner proactively handles credentialing timelines instead of leaving practices to their own devices.
Fast, Accurate Claim Submission
Clean claims submitted quickly mean faster payments. Your billing company should have a track record of high first-pass acceptance rates, not a pattern of resubmissions and appeals.
How to Evaluate Whether It’s Time for a Change?
Sometimes the signs will be clear, such as when the number of AR days increases or the number of denied claims builds up. Sometimes it’s more nuanced, such as if you feel you’re not getting proactive enough from your billing staff. In either case, it’s worth doing the calculations. Track the denial rate, days in AR, and net collection rate and compare them with surgical practice industry benchmarks. If you are always missing, that’s the gap that is your answer.
Another good tip is to pose direct questions. What do your billing partner do if there are any disputes related to the period of the bill? So what do they do when a claim for medical necessity is denied by a payer? Are they able to give you a recent story of how they recovered money that was lost? General responses tend to indicate general processes, and general processes cost.
The Bottom Line
Surgical practices work too hard to let preventable billing errors eat into their revenue. Choosing a general surgery billing company that understands the specialty’s coding complexity, stays proactive about denials, and communicates transparently isn’t a luxury. It’s the foundation of a financially healthy practice.
Outsourcing firms have special expertise in surgical billing, credentialing and revenue cycle management tailored to the needs of general surgery practices. It could be time for a conversation when your current billing partner isn’t providing the transparency, accuracy, and results your practice deserves.
