Top 5 Mistakes In Oncology Medical Billing And Ways To Avoid Them
Many healthcare providers get entangled in the intricacies of oncology billing. The reason is that oncology is different and more complex than other specialties. It involves frequent therapy modifications and expensive drugs, which are difficult to bill. That is why oncology medical billing is more prone to errors than RCM for other specialties.
Where Cancer Care Billing Becomes Complex
The basic steps of oncology RCM and billing are fundamentally the same. But the devil is in the detail. Each of these steps requires extensive knowledge and thorough attention.
Coding
The service documentation provides every detail, including diagnosis, drug, and supply. But deciphering it for correct coding requires a particular skill. That’s because this documentation commonly includes administration codes and codes for actual antineoplastic drugs. There are also revenue codes that tell whether the procedure was performed in a clinic, outpatient hospital, or infusion center. Each facility has a different set of coding rules, adhering to which is crucial for successful claim submission.
Prior Authorization
Most cancer treatments and services require pre-authorization from payers. So, it is essential you get one before providing the service. Additionally, most prior authorizations have short timelines. This gives you a brief time to act.
Claim Submission
Owing to a high risk of denials, scrutinizing an oncology claim before submission is highly crucial. It is not just about ensuring the correct ICD-10/CPT use of codes. You must make certain that all billed and coded details reconcile with pre-authorization and payer-specific requirements.
Patient Responsibility
The high cost of cancer drugs and treatment could mean shared payment responsibility between the payer and the patient. And a patient coming with a liability to pay any part of their bill adds some steps to your RCM workflow, such as:
- Verifying their insurance benefits
- Determining their cost shares
- Establishing a payment plan
- Collecting payment from them
The real challenge here is not just to recover the payment but to do it with empathy. This is possible only when your revenue cycle is fully streamlined and efficient.
Top Mistakes In Oncology Billing
Not Getting Prior Authorization
The prior auth requirements for certain oncology treatments like chemotherapy and radiation therapy can vary radically from payer to payer. Failing to get this important permission where it was needed will give you a denied claim. This will lead you to spend more time obtaining retro auth.
Coding Errors
As mentioned above, the risk of coding errors in oncology billing is higher than in other specialties. And payers do not go lenient on these errors. They simply reject the defective claim. Therefore, it is crucial that you have a team of certified coders who accurately assign CPT treatment, HCPCS medication, and ICD-10 diagnosis codes.
Missing or Wrong Modifiers
Modifier error or misuse is another common reason for oncology claim denials. Modifiers like below are particularly challenging to apply.
- -25: Used for separately identifiable E/M service on the same day as chemo
- -59: Used for distinct procedural service
- -JW: Used for single-use vials where partial drugs go into the waste
Data Entry Mistakes
Oncology claims bring an immense amount of data to deal with. Each claim is a technical discussion of codes, modifiers, and other complex details. Although data entry teams apply their skills to put data into respective categories, errors can still occur. The convenient way to tackle this challenge is to automate the process of entering data.
Not Appealing Claim Denials
Payers deny the claims that do not fulfill certain requirements. But sometimes, they deny claims mistakenly. Therefore, it is a wrong approach not to check whether your claim denial was result of your noncompliance or the payer’s error. In fact, you should have a dedicated framework to analyze all the root causes of denials and apply appropriate rectifications.
How To Avoid These Errors
Implement Automated Claim Processing
Your oncology medical billing will become more error-free with automated billing systems. AI and RPA will particularly help you avoid all the billing mistakes that are common with conventional methods. You will be able to ensure better accuracy in the verification of treatment codes, diagnosis codes, modifiers, units, and charges. The RPA’s rule engines will help check pre-auths more effectively and instantly. In general, automation is the best way to reduce denials, compliance problems, and underpayments and streamline the claim process.
Use Billing Software With Updated Coding Guidelines
Manual coding is no longer an effective way to create claims, especially for a complex specialty like oncology. You will need to use software with AI-based coding frameworks. Most software solutions are designed to get updated with the latest medical coding guidelines. However, taking a back seat, believing that the system will do everything, can sometimes cause problems. Any glitch in the updating process can cause the system to remain stuck with the old database. The result, higher risk for coding errors. Be sure that your software uses the fresh guidelines for coding.
Appeal Claim Denials On Priority
23% of initially denied claims are recoverable through appeals. So you have to be proactive with your appealing strategy. However, this strategy must not focus on basic or most prominent errors only. You should have a solid mechanism to analyze a denial thoroughly and from all possible angles.
It is also important to note that appeal timelines can vary from payer to payer. For instance:
- Commercial payers give a 30-45-day window.
- Medicare gives a 120-day filing deadline.
- Medicaid follows state-specific timelines (often 60 days).
Outsource Your Oncology Billing
The viable solution you can always count on is to outsource your cancer care RCM. A dedicated billing firm knows all ins and outs of oncology billing. They are the better people to handle all its complexities.
At AltuMED, not only do we perform accurate oncology medical billing, but our tech stack is top-of-the-line. We use the best of human expertise and technology to handle all the strategic as well as technical aspects of your practice management.
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