Two Important Questions: Is it Orthopedics or Orthopaedics? Do you Prefer Outsourced Services or In-House Automation?

Presented by ADS and ADSRCM, leading sources of services and automated systems for Orthopedics.

The good news is, there are no wrong answers to the two questions above:

• According to Webster, “orthopaedics” is correct; it’s simply less common than “orthopedics.” (In this paper, we’ll use “orthopedics.”)
• According to us, it’s about what works best for you, whether it’s in-office automation or outsourced services and staffing.

Hope you enjoy the read, which begins with the finer points for orthopedics.

Automation’s Finer Points for Orthopedics

• Faxes. You have incoming referral faxes. That’s great because they represent new patients.

But they need to be read, understood, and then affixed to patients’ records if they already exist, or to newly created records for new patients. You then need to proactively contact those patients to schedule their appointments, rather than waiting for them to call, which may or may not happen.

So while faxes hold the promise of new patients, they can also tie up your staff with plenty of eyes-on/hands-on work. The good news is there’s AI-driven automation for this!

• WC/NF/PIP. In orthopedics, you no likely encounter workers’ compensation (WC), no-fault (NF), and personal injury patients. Claims - especially for WC and NF - are complicated. They need to be submitted cleanly with specific documentation per your state’s requirements.

You’ll want all of your claims, whether WC, NF, PIP, HCFA, or UB, to be submitted with a nearly 100% success rate on first attempt clearing house submissions. Not just submitted, but submitted for maximized reimbursements with complicated E/M and HCC coding, helping to ensure the best possible value on your claims.

• Attorneys. In orthopedics, besides having to manage patients and insurance payers, you almost assuredly have patients’ attorneys in the mix.

You’ll want a built-in Patient Attorney Manager…an attorney database cleanly linking them to their clients (your patients), eliminating the mystery of which attorneys are handling cases for your patients.

And speaking of cases, you’ll want the Attorney Manager to be case-specific since patients with multiple/different accidents may have different attorneys for each one.

A valuable bonus option is a secure, on-demand, self-serve Attorney Portal that empowers attorneys and their staff to access and review information independently, without disrupting your staff and generating zero additional revenue.

You have enough to do administratively without having attorneys to deal with. There’s automation for this.

• Imaging. You might do in-house imaging at a high enough volume to warrant a full-fledged radiology information system (RIS). Either way, you’ll probably need PACS connectivity with the ability to affix images to patients’ records.

A secondary thought on imaging is clinical decision support and the CMS Appropriate Use Criteria (AUC) initiative, which may come back to life in the form of the Radiology Outpatient Ordering Transmission (ROOT) Act with a start date of January 1, 2026, as of this writing.

Regardless of when it starts, the initiative calls for using a qualified clinical decision support mechanism (qCDSM) to confirm your decision to refer Medicare patients for advanced imaging appointments, including CTs, PETs, MRs, and nuclear.

The qCDSM would issue (or not issue!) a G code confirming your decision for the study, all to reduce expenditures on what may be perceived as “cavalierly ordered” studies. Imaging centers that perform these procedures on Medicare patients without G-codes on the referrals would see those claims denied. So, the onus would be on imaging centers to ensure G-codes are present.

You’d need to have those codes produced. There’s automation for that.

• Adjunct Specialties. You might have additional specialties under your orthopedics umbrella, such as physical therapy, pain management, and an ambulatory surgery center with anesthesiology, all of which need to be covered for billing and administrative management.

You don’t want a bunch of disparate systems or outsourced services covering any additional specialties or entities. You’ll want everything together in the “main” orthopedics system, yet be able to view and compile reports, dashboards, and KPIs separately as needed (specialty, tax ID, etc.) or in roll-up fashion for an overall view.

The correct in-house automation or outsourced service should be able to accommodate this.

• Purchasable Products. You might sell products (braces, orthotics, wraps, ointments, supplements, etc.). If you do, there’s inventory to manage, sales tax to calculate, separate payments to take for products apart from payments for medical procedures, and reports to compile specifically for purchasable products.

You could have a separate stand-alone system for this. Ideally, you’d have this capability embedded into your billing/management platform or RCM service, eliminating the need for different systems and expensive interfaces to tie them together.

Having a product management feature as part of your in-house system or RCM service, as described, is possible.

• Advertising/Marketing. You might do advertising/marketing. If so, you’ll want to track how those campaigns are performing. This also includes new patients referred by existing patients. To do this correctly, you’ll need a customer relationship manager (CRM).

Stand-alone CRMs can be very expensive. But what if your management system or outsourced RCM service had a CRM utility embedded into it? Again, you’d eliminate another disparate system, vendor, and interfaces.

Having a CRM utility with your in-house platform or outsourced service is possible.

Any or all of these “finer points” may apply to you. The good news is that there are “under one umbrella” solutions for all of these points, whether you prefer outsourced services and staffing from ADSRCM or in-house automation with ADS.

Driving Orthopedics Revenue and Protecting it in Advance

Revenue Types. You have two types of revenue concerns. There are two aspects: (1) the revenue that needs to be protected in advance, and (2) maximizing the revenue you get. And both apply to each of your payer groups: insurance payers and patients.

On maximizing insurance claims, for example, you’ll want them to be submitted using the correct E/M and hierarchical coding (HCC). Both are often overlooked or simply not applied because they’re so complicated to calculate.

Let’s delve into all of this, starting from before a claim is created. During scheduling, you'll want several actions to happen automatically, and you’ll also need access to other features.

Insurance. You’ll want both eligibility verifications and out-of-network (OON) alerts on scheduling. But here’s a word about each: (1) you’ll also want to batch-verify eligibilities through the scheduler a few times before arrivals to make sure nothing has changed, and (2) you don’t just want “dumb” OON alerts, you’ll want to see any of your other providers who might be in-network for the patient or expected procedures.

Prior authorizations (PA) are even more painstaking and time-consuming. You’ll want an ability to get PAs automatically when needed.

And then obviously, you’ll want to see any “red flag” appointments clearly highlighted on the scheduler, empowering you or your patients to take corrective actions as may be needed.

With these kinds of proactive protections, you’ll be virtually assured that every patient arriving for their appointments has been preapproved insurance-wise, or that any OONs are handled per your financial policy on that.

Patients. As for patient balances, you’ll want to access a patient responsibility estimator as part of scheduling for a close approximation of what they’ll owe after insurance reimburses, assuming they have insurance. The estimator helps avoid surprises (No-Surprises), empowering you to prepare patients for what will be owed based on the expected procedures. Secondarily, the estimator should be accessible as patients leave and after the actual procedures have been performed, as procedures may differ from the expectations at the time of scheduling appointments.

There are still tasks to be completed now that the claims are ready to submit. Have they been maximized for the best possible reimbursements? Are your E/M and hierarchical (HCC) codings optimized? E/M and HCC are often overlooked or shunned simply because they’re so complicated.

And now that your claims have been coded, will they be successful? You’ll want proactive, pre-submission alerts on claims likely to be denied by their payers, with denial reasons enabling you to edit them first and then submit. As a backup for any not pre-detected, you’ll want an easy-to-use denial manager for quickly editing and resubmitting those claims. A special note on denials involves NCCI editing. You’ll want to make sure that multiple claims for a single patient are combined into one master claim when necessary, to avoid all of them being denied. For that reason, you’ll also want alerts on NCCI editing.

Submitted Claims. Okay, now claims are submitted. You’re reasonably sure they’ll pass on first-time submissions, but you don’t want to “submit and forget.” You’ll want to view submitted claims in payers’ queues, in real-time, to ensure they’re being processed. This gives you the ability to nudge or question payers as to why particular claims may be lingering unnoticed.

The final step in insurance reimbursements involves automated EOB reconciliations, which keep your insurance A/R as accurate as possible by eliminating the need for hands-on line-by-line payment reconciliations.

Patient Payments. As patient responsibility balances are created (remember, there should be no surprises!), you’ll want an array of ways for them to pay. Interactive balance-due texting and/or emailable statements, both with payment mechanisms built in, should be available, as should a patient portal with online payments.

Of course, there should be an option for off-site paper statement production/fulfillment if wanted or needed.

Extra feature. An interesting capability, which you may or may not need, is an accurate insurance discovery option for patients who have no insurance listed. A good insurance discovery piece can reveal that as many as 30% of patients with no insurance have coverage.

Your  orthopedics setting can take significant steps to protect itself in advance and effectively capture insurance and patients’ payments. ADSRCM and our team perform much of what has been described for clients, while ADS clients use MedicsPremier as an in-house platform to do so.

Clinical Charting for Orthopedics

Charting for orthopedics - almost by definition - means lots of dictation, transcriptions, and reports regardless of whether they’re for PIP encounters. Of course, PIPs (including WC and NF) have their own specialized requirements for reports.

Additional Specialties. If you have ancillary specialties such as pain management, those clinical charting sessions can be equally as complicated.

Expedited Encounters. To say you’ll want specialty-specific templates is an understatement. But besides having the correct content and templates, you’ll want the ability to complete encounters and records as close to “on the fly” as possible. Ideally, you’ll want reports constructed and records completed essentially as encounters happen.

Coding for Revenue. Simultaneously, in addition to completing encounters as described, you’ll want the EHR to calculate complicated E/M and HCC coding, also on the fly, so that claims are submitted for maximized reimbursement without requiring task-heavy human input. Additionally, receiving warnings when multiple claims for a single patient should be bundled into a master claim (NCCI editing, common in orthopedics) to avoid denials would be an added plus.

Comparisons and Outcomes. You’ll want a quick way to invoke details of a patient’s previous visits to chart how the patient is improving, including an ability to easily view images as attached to the patient’s electronic record.

Medication Management. While it may be a given, you’ll want your EHR to have a comprehensive medication management capability and an ability to prescribe (e-Rx) for controlled substances electronically. You’ll want warnings, for example, on medication interactions and how often controlled substances are prescribed for any one patient.

Decision Support. As detailed above, clinical decision support (CDS) may become a reality. If you refer Medicare patients for advanced imaging appointments, the EHR ideally will have an embedded qualified clinical decision support mechanism (qCDSM) that will confirm your decision for ordering the study by issuing a G-Code, thereby avoiding a Medicare denial for the imaging center.

(MedicsCloud EHR. You’ll want a lot more than “straight ahead” clinical charting from your EHR. ADSRCM and ADS clients have access to the ONC-certified MedicsCloud EHR, which supports everything mentioned, and which has the MedicsScribeAI for ambient, natural language data capture during encounters. Virtually hands-free/voice-navigated, you’ll spend more time focused on your patients and less on your displays and placing cursors where they should go next!)

Workflow and Productivity for Orthopedics

You want fluidity and motion for your patients. You also want it for your workflow because bottlenecks and speed bumps drag your entire ecosystem of patients, providers, staff, and resources.

That’s why in addition to managing appointments, your scheduler must also be a workflow - and yes, a revenue generator - as well.

Appointments. Scheduling appointments is what an appointment scheduler should do. But it should empower you to schedule intelligently by considering the staff/resources/equipment that may be needed for a particular patient. By doing so, workflow and productivity would be dramatically improved.

The scheduler should operate centrally or by place(s) of service if you have more than one location. You might want to see appointments based on provider(s), tax ID(s), appointment type(s), expected procedure(s), payer(s), referral sources, appointments with issues (e.g., eligibility or prior authorizations needed), or any number of essentially limitless parameters.

Revenue. The scheduler should support verifications and out-of-network alerts during scheduling, and also enable batch verifications in advance. Additionally, it should provide access to a patient responsibility estimator during scheduling.

You’ll want interactive appointment reminder texting, which helps eliminate no-shows by enabling patients to confirm or cancel through their texts. Either response type must be visible on each corresponding appointment. With that, you’d be able to quickly reschedule cancellations and move future appointments into open slots to keep your scheduling as tight as possible.

Other Specialties. The scheduler should accommodate any other specialties under your umbrella and be able to schedule coordinated appointments as needed, such as an appointment with the orthopedist followed by one for physical therapy, etc. If there is a physical therapy component, the scheduler should support easy-to-schedule multiple appointments for the patient in the future for a specified amount of time.

Appointment Analytics. You’ll want appointment-related analytics. So, in addition to viewing appointments by any number of ways as noted above, you’ll also want to produce analytics on them. And you’ll like these scheduler analytics/reports/dashboards to be compilable by any number of user-defined parameters.

The scheduler is, or should be, way more than a mechanism to schedule appointments. It must be a dynamic producer of efficiency and workflow, intelligence, and revenue (as is the MedicsPremier scheduler for ADS and ADSRCM clients).

Financial and Operational Analytics for Orthopedics

You’ll want four types of financial and operational analytics:

• historical, based on what happened in the past
• current as to how things are going right now
• the future to see projections as to what will happen
• any combinations of these for from/to comparisons

Historical and current are apparent, but future? Yes, with access to predictive analytics, you can see how things will go, identify where corrections are needed to avoid issues, and enhance strengths to accentuate the positives.

You’ll want reports, KPIs, and dashboards to be user-defined with a virtually limitless number of parameters and filters. You should be able to drill into a particular field to see more details specific to the field. As defined by the user, they should be savable, then named, and scheduled to compile automatically as needed by the user. They must be exportable to Excel.

Outsourced RCM note. If you’re working with an outsourced RCM company, they should routinely compile reports for you and review them with you as well. But you’ll want 100% transparent access to all your data and be able to generate any report as well on demand, to the extent you want.

A good RCM company would encourage you to see what they see and provide training on how to create reports.

The Dark and the Light. You can operate in the dark (“head in the sand”) financially and operationally, but if you’re a stakeholder in an orthopedics group, you know that’s not the way to go. Instead, you’d be in the light on strengths and weaknesses with dynamic, user-defined reports, analytics, KPIs, and dashboards presenting a picture of past, present, and future.

(ADSRCM and ADS support you being in the light as described.)

We hope you enjoyed the read. Contact us at 800-899-4237, Ext. 2264 or email info@adsc.com for more about outsourcing with ADSRCM, about using the MedicsCloud Suite as an in-house platform from ADS, or about both if you’re unsure. We’ll help you drive revenue, productivity, clinical charting with MedicsScribeAI, and more, all in ways that work best for you!