SunKnowledge has added another established orthopedic solutions company to its clientele, focusing on orthotics and prosthetics (O&P) eligibility verification and insurance benefits checks. The engagement is designed to help the provider manage increasing administrative demands while allowing its patient service staff to spend more time assisting patients.
The client, a large company serving communities across western Pennsylvania, eastern Ohio, and West Virginia, combines orthopedic products with specialist fitting, patient education, and continued support. With approximately 600 orders a month, the client needed more support to keep up with insurance verification. Even as the team grew, these tasks took up much of the staff's time, prompting the company to seek SunKnowledge's help within its existing processes.
Much of the workload involves contacting insurers and checking benefits, as well as obtaining information not consistently available through online portals. Long payer hold times made it difficult for staff to predict how much of the day would be spent on a single verification. SunKnowledge's proposed support addresses these demands through a dedicated eligibility and benefits verification workflow and a team that will ensure the work is done seamlessly, using payer portals where sufficient information is available and contacting insurance representatives when additional details are required.
"Orthopedic providers put a great deal of care into making sure patients receive the right product, a proper fit, and clear instructions," said Ronnie Hastings, spokesperson for SunKnowledge. "The administrative work behind that service deserves the same attention. Our role is to handle detailed insurance verification so their patient service team has more time to help patients."
The engagement involves more than checking whether a patient has an active insurance plan. The client needs proper verification that considers the prescribed product, relevant Healthcare Common Procedure Coding System (HCPCS) codes, and the payer's applicable medical policies. Depending on the order, the review may also involve available billing history, frequency limitations, and documentation requirements. This level of detail is especially relevant to custom bracing and ankle-foot orthoses, where an active policy does not by itself establish that a particular orthosis meets the plan's coverage conditions.
SunKnowledge's responsibilities include reviewing available documentation against applicable payer requirements and identifying missing information or questions requiring further follow-up. Treating professionals remain responsible for clinical decisions, and insurers retain responsibility for coverage determinations. Eligibility and benefits verification does not guarantee payment, but documenting what has been verified and what remains unresolved can help the provider recognize coverage concerns earlier.
The client currently uses Nimble, and SunKnowledge confirmed prior experience with the platform. The proposed workflow will use secure, authorized access and follow the organization's existing processes, allowing the client to add verification support without a major change to daily work. The initial scope centers on eligibility verification and benefits checks, with a flexible service model that could allow additional functions such as prior authorization, billing, denial management, and document management in the future, subject to a separate agreement.
For the orthopedic solutions company, the immediate objective is to add administrative capacity while maintaining attentive service. For SunKnowledge, the new engagement expands its work with orthopedic providers and reinforces the importance of detailed verification support.
