A Guide for Oncology practices

Maintaining financial stability is as important as achieving excellent outcomes in the field of oncology care. Successful revenue maximization in an oncology practice means that we have to fully understand the revenue cycle in terms of complexity. This comprehensive guide not only covers the essential steps of practice management but also offers you effective strategies to optimize them all. Through these strategies, you will be able to simplify and standardize your oncology billing operations, enhance coding accuracy, and, in turn, improve the financial status of your practice while keeping in mind what is most important for your cancer patients: their wellbeing.

Understanding the Revenue Cycle in Oncology Practice

The revenue cycle of oncology is the engine of financial stability. It contains all operations and financial expenses related to patients who are diagnosed with cancer. The cycle is initiated with scheduling appointments and confirming patient insurance eligibility. Then, it goes through patient encounters, accurate recording of the services rendered, and correct coding for billing. Next, those claims are then electronically submitted to insurance companies for reimbursement. The cycle is not over yet – it includes remedying denied claims, managing patient payments, and making sure that all revenue is recovered. Knowing and fine-tuning every phase of the process is key for oncology centers to continue staying competitive and providing best care to their patients.

List of Common Oncology ICD-10 Codes

Codes play a vital role in oncology for accurate billing and timely reimbursement. They act as a common language understood by every entity in the healthcare industry. Here is a list of all the important ICD-10 codes used by oncologists: 

Cancer Site  ICD10 Codes Description
Esophagus C15 Malignant neoplasms of the esophagus.
Colon, Rectum, Anus C17 Malignant neoplasms of the colon, rectum, anus, and anal canal.
Lip, Oral Cavity, Pharynx C00 – C06 Various malignant neoplasms of the lip, mouth, tongue, and throat.
Stomach C16 Malignant neoplasms of the stomach.
Pancreas C20 Malignant neoplasms of the pancreas.
Liver, Intrahepatic Bile Ducts C19 Malignant neoplasms of the liver and bile ducts within the liver.
Melanoma, Other Skin Cancers C43 – C44 Malignant melanomas and other skin cancers.
Other Intestine C18 Malignant neoplasms of the appendix, small intestine, and other intestinal sites.

Benefits of Revenue Cycle Management for Oncology Practice

An optimized revenue cycle brings some real benefits to oncology practice. This includes 

  • Reduced Denials for Smoother Treatment
  • Increased Revenue and Collections
  • Workflow Optimization based on Data Driven Solutions
  • Reduce Past-due Payments
  • Enhance Practice Analytics
  • Compliance with Regulations
  • Higher rates of error free claims

Challenges in Oncology Revenue Cycle Management

Oncology practices have to face some serious challenges that impact the whole revenue cycle process. Following are the major causes:

Rapid Treatment Evolution and Coding Updates

Oncology has undergone many transformations, with constantly emerging new therapies and treatment regimens. A 2023 report from the American Society of Clinical Oncology (ASCO) predicts that more than 1500 clinical trials for cancer treatment are currently in progress in the United States itself.

Coding systems may find it hard to follow in terms of reimbursement bills since it is an unfamiliar area, while clinicians excel in patient care and associated specialists. The American Hospital Association (AHA) reports that a significant delay in coding revisions has made the implementation of new cancer treatment codes challenging for about 90% of the hospitals surveyed. The unfamiliarity with a new terminology set adds to the confusion and uncertainty. This process may require more time and effort to properly code the procedures, which may result in denials or under-coding, ultimately resulting in revenue losses.

High-Cost Drugs and Complex Billing

Chemotherapy often comprises drugs that require complicated claims-dealing. The NCI report from 2022 estimated the average cost of oral anticancer agents to exceed $100,000 per month. Such drugs frequently have their own ways of handling or administration that differ from the norm. They might also have special classifiers for claims submitted to the insurance company.

The different types of complexities in the services became one of the impediments to recognizing faults and emerging with chances of net sales. The “AAPC 2023” study stated that average specialty medication claims related to oncology billing errors led to losses of about $2500 per claim.

Managing Multiple Payers and Treatment Phases

Targeted oncology patients frequently deal with several payers during their course of treatment. It may include primary care, oncology, hospital, and pharmacy, potentially requiring different methods for collecting a bill and authorization. A 2022 KFF study reveals that at least two couples insure a comparable number, over 30%, of cancer patients during their treatment.

However, the intricacy of this process and the need to secure proper reimbursement from multiple payers make it quite complex and add pressure. According to a 2023 report by the MGMA (Medical Group Management Association), oncology practices use an average of 20x more as compared to other specialties on complex payer rules and authorization management processes.

Clinical Trials and Research Integration

Clinical trials and research are usually at the forefront of oncology practices. However, in most cases, the billing for these services is complex, and they always require highly specialized expertise. The ACRO (Association of Clinical Research Organizations) statement of 2022 revealed that the oncology sector had over 60% of clinical trials taking place in America.

Synchronizing clinical trials and research services with the revenue cycle can be complicated, resulting in revenue gaps. In 2023, the ASH study concluded that 1.5 to 2.5 billion dollars a year remain untapped because of the poor billing and coding practices of oncology practices related to patients participating in clinical trials.

Strategies for Optimizing Revenue in Oncology Practices

The following list can help oncologists mitigate all the challenges they face on a daily basis:

  • Integrate oncology-specific RCM software that has features like prior-authorization workflows, automated eligibility verification, and electronic claim submission. 
  •  Conduct training sessions every 3–4 months for billers and coders on the latest oncology guidelines set by regulatory bodies. 
  •  Designate a team of billers who are solely dedicated to obtaining prior authorization.
  • Develop standardized oncology documentation templates to remove any errors during data entry.
  • Provide EHR-RCM system integration, which will lead to a streamlined data flow and a reduction in manual errors. 
  • To ensure that communication channels are intact, create specific payer relationship managers. 
  • Create a real-time authorization tracking mechanism to monitor timelines and immediately pursue pending approvals. 
  • Ensure the application of regulations in oncology coding by conducting regular accountability audits through compliance reviews. 
  • Work together with mental health professionals to establish complete patient care services. 
  • Advocate for the inclusion of psychosocial oncology services in medical insurance (consider bundled payments or value-based care models). 
  • Collaborate with CROs who are knowledgeable about oncology billing and reimbursement.

 

Strategy  Description Benefits
Implement Oncology-Specific RCM Software Utilize software with features like: * Prior authorization workflows * Automated eligibility verification * Electronic claim submission Streamlined workflows, reduced manual errors, improved prior authorization management
Regular Staff Training (Every 3-4 Months) Conduct training sessions for billers and coders on: * Latest oncology coding guidelines * Regulatory updates Improved coding accuracy, reduced claim denials
Dedicated Prior Authorization Team Designate a team to specifically handle: * Obtaining prior authorizations * Following up on approvals Faster turnaround times for authorizations, improved revenue cycle efficiency
Standardized Documentation Templates Develop templates for oncology documentation to: * Ensure consistent data capture * Minimize data entry errors Improved claim accuracy, reduced denials due to missing information
EHR-RCM System Integration Integrate your EHR with your RCM system to: * Automate data transfer * Reduce manual data entry Streamlined data flow, improved efficiency, reduced errors
Dedicated Payer Relationship Managers Assign specific payer relationship managers to: * Maintain communication with payers * Resolve billing issues promptly Improved communication, faster claim processing, reduced denials
Real-Time Authorization Tracking Implement a system to track: * Authorization timelines * Pending approvals Proactive management of authorizations, faster approvals, reduced delays
Regular Compliance Reviews Conduct regular audits to ensure: * Adherence to oncology coding regulations * Accurate claim  Reduced risk of penalties, improved claim acceptance rate
Collaboration with Mental Health Professionals Partner with mental health professionals to offer: * Comprehensive patient care * Support for psychosocial needs Improved patient outcomes, potential for bundled payments for holistic care
Advocate for Psychosocial Services Coverage Advocate for insurance coverage of: * Psychosocial oncology services * Consider bundled payments or value-based care models Improved patient well-being, potential for increased revenue through expanded services
Collaboration with Knowledgeable CROs Partner with Contract Research Organizations (CROs) with expertise in: * Oncology billing and reimbursement * Clinical trial coding Improved navigation of complex regulations, optimized reimbursement for clinical trials

By implementing these strategies, oncology practice can achieve financial stability and provide exceptional patient care.

Outsourcing Oncology Billing Services: A Solution for Streamlining Revenue Cycle Management

Considering the billing complexities, integrating oncology billing services into your practice may be a smart move. Medical billing firms, such as Medheave, which deals primarily with oncology practices, have a staff of experienced, competent professionals who know the intricate details of cancer care coding and reimbursement. Thus, you will be able to invest your precious time and in-house resources to deliver the best patient care. 

At Medheave, we provide efficient coding that facilitates prior authorization and smooth claim submissions, which in effect maximizes your revenue collection so you can pay attention to what is paramount: the patients. 

To know more about our oncology billing services, feel free to contact us at (888) 487-1178 or email at [email protected]

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