Originally posted by Opie Choice
If you manage an orthotic and prosthetic practice, you know that the fiscal health of your business relies on effective and compliant billing. While that seems straightforward enough, the scrutiny of the Office of the Inspector General (OIG) has underlined the importance of doing things the right way, the first time, so you can get and keep your money and avoid costly audits and denials.

The simple truth is that 90 percent of denials are preventable, and 2 out of 3 denials are recoverable. I’m going to share some strategies for getting and keeping your money by successfully managing audits, denials, and appeals.

What Can We Do?


That’s obvious enough, but incredibly true. According to Haines and Morgan, 90 percent of denials are avoidable. That means that we have the power to make sure they don’t happen to us, or to our patients.

Why Do Denials Happen?

Understanding why denials happen can help us to prevent them. Most denials occur because of the following:

  • Ineligible/Uncovered Services
  • Failure to Obtain Prior Authorization
  • Lack of Proven Medical Necessity
    • Medical Records
      • Diagnosis
  • Incomplete or Inaccurate Patient Demographic Information
  • Service Covered by Another Plan/Payer

How Can We Prevent Denials?

Now that we know the basis for most denials, we can see that prevention is in the hands of your entire office. Right now we will focus on how the front office can work effectively to prevent denials. Investing in your billing practices will save time- and money- in the long run. These should be a mainstay in your front office procedures:

  • Thorough Patient Intake and Accurate Data Entry
  • Insurance Verification and Prior Authorization
  • Obtaining External Medical Records for Patients
  • Ensuring Clinical Documentation is Complete and Compliant
  • Scrubbing the Bill/Claim Prior to Submittal

What Should We Do if We Are Audited?

Audits happen. The most important thing for you to do is not to panic and to make sure you follow these steps:

  • Respond in a Timely Manner
  • Do NOT Fail to Respond (even if the amount is low, you do not want an error on record)
  • Be Polite
  • Keep Track of ALL Correspondence
  • Thoroughly Respond to the Request
  • Do NOT Alter Records in ANY Way
  • Request “Return Receipt” When You Send Records
  • Ask when You Will Receive a Response

What About Appeals?

If your claim is denied outright or after an audit process, and you disagree with the findings, you can issue an appeal. Remember, 2 out of 3 denials are recoverable. That’s because the denial is usually based on incorrect or incomplete information. The appeal is your opportunity to make things right. Not only is it generally in the patient’s best interest, it will also help you tighten your own processes and, quite possibly, receive the funds you’re hoping for.

What’s the Bottom Line?

While it’s true that O & P practices are subject to denials and audits now more than ever, it’s also true that we have the power to get and keep our money through solid front office/billing procedures and proper management of audits and appeals.


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