Running a financially successful cancer center or oncology practice depends on having strong, reliable processes in place. Some of the most critical ones include:
- Verifying insurance coverage
- Capturing all billable items
- Submitting clean and compliant claims for billing purposes
- Ensuring collection of appropriate payments.
Each of these processes is more complex for oncology than for virtually any other service line. For radiation services, this complexity stems from the use of multiple modalities and continued advancing technology which can lead to new billable CPT® codes. A review of the revenue cycle for radiation oncology services should consist of the following:
A hard-wired process should exist for insurance verification and prior authorizations. This process should take place prior to the patient receiving treatment. Use real-time eligibility verification to confirm eligibility, including co-pays, deductibles, and co-insurance This allows the patient to understand their out-of-pocket obligations prior to the start of treatment. Regular updates to check any changes to the patients’ insurance coverage and status of lifetime benefits should occur.
Regulatory changes and payer updates occur frequently and not necessarily at a scheduled time. The chargemaster should be reviewed on a regular basis to ensure that all appropriate codes are present and accurate. An in-depth review should take place on a quarterly basis to coincide with corrections and updates released by various sources such as CMS. Updates to modifiers should also be a part of this review. The complexity of payer medical policy updates can be overwhelming. A staff person must be responsible for reviewing the volumes of these guidelines and ensure the physicians and authorization staff are educated on any new guidelines.
A methodical and meticulous review of the processes for charge capture, charge entry and bill production should be undertaken on a regular basis, especially if staff turnover is an issue. Staff should be trained on how to select the correct charge, and a check and balance system should be in place to ensure no charges are omitted. The individual responsible for charge entry should also be trained to double check for missed charges. Meticulous attention should be paid to reconcile each patient’s appointment with the charges on a daily basis. Lastly, a system to ensure that the charges actually make it to the claim completely and according to payer requirements should be in place and reviewed for accuracy.
A verification process should be in place to ensure that the documentation in the clinical charts for all services rendered is appropriately coded and charged. This includes:
- Accurately documenting all physician orders including medical necessity
- Detailed and accurate procedure notes for each procedure
- Diagnosis codes sourced directly from physician documentation
A system should be in place that verifies that documentation and claims meet current Medicare rules. An in-depth audit with an ample sample size of courses of radiation therapy should be conducted to get a clear picture of comparing the medical record documentation to the claims. Line-item detail should be reviewed to ascertain appropriate payment.
Best practices across the country are placing a strong emphasis on front-end processes ensuring that all authorizations are in place. Given the declining reimbursements for radiation oncology practices, all staff and physicians must maintain a focus on the revenue cycle in order to survive. Reducing rework and eliminating redundant processes greatly enhances the operation and can lead to enhanced throughput. Hardwiring prospective processes for sending an accurate, clean claim greatly improves cash flow and eliminates the need for retrospectively correcting errors.
Staff and physician training should occur on an annual basis and during orientation for any new employees. Role specific training should occur for those employees conducting insurance verification, prior authorization, charge capture and coding. Obtaining certification in a clinical specific specialty is considered best practice for coders.
By proactively addressing all of these steps in each process that leads to a claim submission, practices can significantly increase the clean claim rate and reduce denials. This ultimately leads to the improvement of efficiency and accuracy in the revenue cycle, leading to improved cash flow and a more sustainable operation.
