Oncology

Here are some key aspects of oncology medical billing:

• Multidisciplinary care – Cancer patients interact with a variety of specialists including oncologists, surgeons, radiation oncologists, pathologists, radiologists, and hematologists. Appropriate coordination and documentation is crucial for accurate coding and billing across specialties.
• Multiple service locations – Cancer care requires services delivered in multiple settings including outpatient clinics, infusion centers, hospitals, and independent diagnostic testing facilities. Oncology billers must understand documentation and billing requirements across sites of service.
• High cost medications – Oncology practices often administer expensive injectable or oral anti-cancer drugs. Strict adherence to coding guidelines and billing units is essential for proper reimbursement.
• Clinical trials – Patients may participate in clinical trials for experimental treatments. Billing these services requires researching trial protocols, payor coverage, and proper trial-specific coding.
• Prior authorizations – Oral cancer drugs and expensive treatments often require upfront insurance authorizations before services are delivered. Billers must proactively manage prior auth requests and denials.
  

Here are some key coding considerations:

• ICD coding – Selecting the right ICD diagnostic codes is crucial for documenting the patient’s cancer type, stage, metastases, and any complications impacting treatment.
• CPT coding – Oncology services use a range of CPT codes for evaluation and management, procedures, radiation therapy planning and delivery, chemotherapy administration, and more.
• HCPCS codes – The HCPCS system includes codes to identify drugs, biologicals, and supplies needed for cancer care.
• Modifiers – Modifiers provide additional information to insurers about certain services, like chemotherapy administration routes or billing for discarded drugs.
• RADV audits – CMS uses RADV audits to review radiation oncology billing and coding. Practices should ensure documentation supports coding choices and reflects true patient care needs.
• Billing lab services – Pathology and lab services for tumor testing, biomarkers, and monitoring must be coded accurately and billed in coordination with treating oncologists.
  

Unlike other specialties, oncology faces distinctive reimbursement difficulties:

• Lower payouts – CMS and private insurers have systematically reduced reimbursements for cancer care services like chemotherapy administration and drug payments.
• Drug reimbursement – Insurers are increasingly implementing tactics like prior authorization, billing edits, and formulary restrictions to limit costs for expensive IV and oral oncolytic agents. This leads to more rejected payments that staff must appeal.
• High denial rates – A 2021 survey found oncology practices experience denial rates 2-3 times higher than other specialties. Denials consume significant staff time to re-submit and appeal claims.
• Compliance risk – Complex documentation rules and evolving payer policies create compliance risk for oncology billing. Practices that unknowingly code or bill incorrectly can face insurance audits, penalties, and charges of fraud.
• Patient financial toxicity – Even with insurance coverage, high out-of-pocket costs are a barrier for many patients. Oncology financial counselors are crucial to minimize patient financial toxicity.
  

To overcome reimbursement obstacles, oncology billing departments must take proactive steps to optimize the revenue cycle:

• Utilize specialty software – Oncology-specific practice management and billing software has built-in tools to simplify complex billing tasks and improve clean claim rates.
• Verify eligibility – Checking patient eligibility and benefits up front helps avoid issues after services are delivered and identifies coverage for clinical trials.
• Obtain pre-authorizations – Securing insurance approvals for expensive treatments before administering prevents payment denials down the line.
• Review EOBs – Audit explanation of benefits showing how insurers processed claims to watch for trends in underpayments, rejections, and payer errors.
• Appeal denials – Denied claims should be promptly appealed with clear documentation justifying medical necessity. Identify trends in reasons for insurer rejections.
• Monitor metrics – Key performance indicators like days in A/R, denial rates, collection rates, and net collection percentages should be tracked to improve processes.
• Address patient costs – Use financial coordinators to estimate costs, set up payment plans, enroll patients in financial assistance, and complete prior authorizations.
  

Several major trends are impacting oncology reimbursement and revenue cycle management:

• Value-based contracts – Government and commercial insurers are pushing payment models that tie reimbursement to quality and costs, such as bundled payments for episodes of care. This requires more data analytics and coordination across providers.
• Site-neutral payments – CMS has proposed site-neutral payments to pay the same rate for clinic or hospital outpatient cancer care services. This will cut reimbursement for hospital-owned practices.
• Raising patient costs – Payers are shifting more treatment costs onto patients through higher deductibles, co-insurance, and expanded use of specialty tiers for costly drugs. Practices must have financial navigation resources to help patients manage out-of-pocket expenses.
• Automation – New technology like robotic process automation can streamline repetitive billing tasks, boost staff efficiency, and reduce billing errors and delays.

As cancer care delivery evolves, medical billing services must position their practices for sustainable success. Investing in engaged staff, efficient processes, and data-driven decisions will help oncology practices optimize reimbursement in a climate of tighter payor controls.