Insurance reimbursement in the oncology market

According to a new study by IMS Institute for Healthcare informatics, "The global oncology drug market is expected to reach $ 150 billion by 2020 from $ 107 billion in 2015 – registering an annual growth rate of 7.5-10.5 percent through 2020" ( This growth is attributed to innovations in healthcare; in the past five years, more than 70 new cancer treatments have been initiated. However, as these are not readily available in the market, many of them are not reimbursed by the insurance payers for the patient and/or the practitioner. But health insurance is valuable, and is taken to avoid financial risks. This article deals with the two models taken into consideration for increasing the practitioners' insurance reimbursements for oncology medical billing services.

Oncology Care Model:

New payment models, especially for those providing oncology medical services, have been designed to improve the value and effectiveness of medical care. For this, the Centre of Medicare and Medicaid Innovation devised a new model called the 'Oncology Care Model.' "Under the Oncology Care Model (OCM), physician practices have entered into payment arrangements that include financial and performance accountability for episodes of care surrounding chemotherapy administration to cancer patients. There are 195 practices and 17 payers participating in the Oncology Care Model" ( Along with Medicare, this model also partners with other private payers. It aims for 3 goals...enhanced care, smarter spending and people in good health. As a value-based reimbursement via oncology billing and coding, the oncology practitioners acquires the infrastructure and competencies while delivering treatments at a low cost. According to, the six requirements for participation include:

  • Provide patient navigation services
  • Develop, follow and document a care plan that incorporates the 13 elements of high-quality cancer care as defined by the Institute of Medicine
  • Use a certified Electronic Health Record (EHR) system that meets the Stage 2 "meaningful use" requirements as defined by HHS
  • Provide 24/7 patient access to clinicians with real-time access to patients' medical records
  • Treat patients with recognized and evidence-based clinical therapies
  • Use data to drive continuous quality improvement

Medicare also pays a per beneficiary payment ($160) above the regular payment (performance based) thereby increasing patients and revenue opportunity for those payers and practitioners providing oncology medical billing services. This also tends to strengthen and encourage other practices to invest in additional resources required for patient care along with adding particular quality measures in their practices. Upgrading of EHR systems and other practice management software are required to identify the patients eligible for the OCM model along with collecting data on 36 quality metrics required by the OCM program. These details are then required to be reported to Medicare. This program is available to practices that provide chemotherapy to Medicare cancer patients where the duration is six months and begins with the first chemotherapy. Once the technology is in place, the practices need to train and educate their staff on handling these requirements. A workflow must be created where the staff can handle the enrollment of patients in the program, bill Medicare for the per beneficiary per month (PBPM) fee, provide services as a patient navigator and ensure that all documentation is in sync with the OCM program's prerequisites. Again, additional revenues can be provided on a performance payment basis if the practices manage to give priority to services that decrease costs and improve the treatment services.

Performance based oncology care:

The model addresses three key issues in the oncology practice that believes in value-based agreements, and are the cost drivers of oncology billing and coding:

Avoiding hospitalization: As per the innovent program, a nurse call center is established in which innovent nurses have access to the patient's medical record. These nurses are required to take care of the patients and counsel them as and when required (in sync with the patient's values). Extended clinic hours aid the patient in obtaining outpatient care rather than getting admitted in emergency rooms thereby lowering costs.

Reducing chemotherapy costs:
This has to be done while keeping the costs low. This can be achieved by conducting conversations on advanced care and planning, pursuing clinical pathways that have been accepted throughout, and regulating the delivery of care and business operations.

Standardization and resources:
Use resources in a variable manner and use clinical pathways as a practice. Clinical pathways tend to reduce the unnecessary variables in the treatment of cancer. It also improves the workflow of practitioners leading to operational efficiency leading to lesser waiting time for patients.

It is ultimately all about adhering to substantiation based medicine, and providing high value-low cost treatment services with enhanced outcomes for cancer patients.

Published By - Medical Billers and Coders
Published Date - Oct-03-2016 Back

Looking for a Medical Billing Quote?

Are you looking for more than one billing quotes?



Looking for a Medical Billing Quote?

Are you looking for more than one billing quotes ?





Would You like to Increase Your Collections?