SunKnowledge has added an 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. For the orthopedic solutions company, the immediate objective is to add administrative capacity while maintaining the attentive service its patients receive.
The client, which serves 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. Much of that workload involved 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, competing with patient questions, follow-up activities, and other service responsibilities.
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. The team will use payer portals where sufficient information is available and contact insurance representatives when additional details are required. This work is intended to help the client's internal staff receive clearer verification information while reducing the number of insurance inquiries they must handle directly. "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. We will work within their established processes and focus on the coverage questions that need to be answered for each order."
The engagement involves more than checking whether a patient has an active insurance plan. The client needs proper verification that considers the prescribed product, the 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.
The client currently uses Nimble, and SunKnowledge confirmed prior experience with the platform during discussions. The proposed workflow will use secure, authorized access and follow the organization's existing processes, allowing the client to add verification support without introducing a major change to how its staff manages daily work. The initial scope centers on eligibility verification and benefits checks, but SunKnowledge has also offered a flexible service model that would allow the client to consider additional functions such as prior authorization, billing, denial management, and document management as its needs develop. For SunKnowledge, the new engagement expands its work with orthopedic providers and reinforces the importance of detailed verification support, helping the client manage its order workload, clarify insurance requirements, and give patient service employees more time for the people who rely on them.
