Augmented revenues and focus on patient care...is the aspiration of every practitioner/healthcare center. However, most of the medical specialties get hit due to mistakes in billing and coding (incorrect modifiers or inappropriate documentation) leaving revenues on the table. The same holds true for oncology; especially with strict Medicare rules for reimbursement.
This practice also faces reduced reimbursements due to over-coding, ignorance of payer guidelines, compliances not being followed, loss-making reimbursements on drugs, and/or Medicare reimbursement on chemotherapy administration, only on the condition if a cancer diagnosis is given to the patient by an oncologist, thereby drastically eroding revenues.
Increase use of oral oncology agents over traditional infusion-based therapies and alternative business models for oncology practices. (www.pharmaceuticalcommerce.com).
Concentrate on the usage of clinical ways which focus more on efficient therapies; make use of diagnostic tests and biomarkers which are able to target the patients who can probably benefit from other successful therapies.
To garner revenues, oncologists can buy and store infusion based drugs, or injectable therapies, through direct wholesalers or group purchasing organizations.
Oncology practices working from within the hospital tend to benefit from 340B drug pricing plan which allows them to buy drugs at discounted rates.
Apart from ensuring that the coders are well aware of the latest codes and insurance payer's guidelines, it is imperative to ensure that every patient is billed in the first place. Also, as oncology is about treating extremely sick patients, it is possible that many come not as per their appointment schedule, hence it is important to ensure that such patients' billing does not go missing and each one is billed appropriately.
It is essential for the oncologists to monitor drug inventory. In-office infusion used to be at high risks with high reward, but it has lately become a high risk but a moderate reward venture. Evaluate the records for every drug that was ordered, and compare it to pulling from inventory and its administration, creating a balance in all three columns.
Under the current ASCO plan called 'Consolidated payments for Oncology care,' oncologists would receive 4 monthly payments per patient (and their stage) for patients who require monitoring and for clinical trials, and 5 types of bundled payments to cover reimbursements lost due to time and cost, along with separate reimbursements for drugs, tests and major procedures.
Any errors in the billing procedures can delay payments, or lead to a loss in revenues. Hire competent billers who have the required knowledge for oncology billing on complex codes, modifiers, billing particulars, regarding chemo/non chemo drugs and injections, bundling of procedures/code bundling, and therapeutic infusion.
These professionals must be able to file clean claims without delay; and if a claim is denied, then it must be sent back after a thorough check of the cause of denial rather than a quick resubmission resulting in a duplicate bill, thereby losing time and money. This is also essential as different payers use different codes for denial reasons hence the explanation of benefits must be evaluated before resubmission of the claim.
This analysis states the revenues owed to the practice. Check your A/R days, which is usually in batches of 30 days till 120 days, starting from the date of service being 0 (0 to 30 etc.). A/R should be below 90 days. In fact only 15-20% of the accounts may exceed 90 days. If longer, it can create a dent in revenues.
As with all processes, check insurance coverage at the time or pre-registration (before the patient's first visit). At the time of the visit, confirm demographics, and ensure that the ID name and number matches on the insurance card and your records. In Oncology, the co-pays/deductibles (from patients) are to be collected after the physician visit.
Post this; claims must be filed daily rather than weekly or monthly, reducing submission issues. Claims must be submitted electronically; leading to cleaner, faster, and timely claims. An electronic claims scrubber can be used to check for generic errors such as month date (ends-30 or 31), ZIP codes etc. whereas more sophisticated claims scrubber can be used to check for patients ID (prefix and suffix) etc.
All of the above aspects need to be in place for efficient, flourishing and tenable oncology billing services.
