When you ask an oncologist where their day goes, the answer will likely be more than “seeing patients.” It includes tumor board meetings, talking on the phone with other specialists such as surgeons and radiation oncologists, playing phone tag with the patient’s primary physician, and a great deal of time spent organizing scans and other tests, all of which contribute to the care of the patient. None of this, actually ends up being billed for.
This is not a failure of care but of billing; a failure that the specialty of oncology billing services is tailor-made to address.
The Work Nobody Sees on the Invoice
Treatment of cancer patients involves a lot of people working together. Just one newly diagnosed patient, a medical oncologist, a surgeon, a radiation oncologist, a pathologist, and a radiologist will have to discuss the best course of action for treatment. Following that, someone would have to ensure the treatment plan is followed through, schedules are made, a nurse will monitor any side effects, social workers will arrange for transport, and inform all other physicians involved.
The practice does it for its patients. However, when it treats it as an overhead expense but not as a service that could be reported, they lose thousands of dollars each year. Eventually, with all the loss they suffer, it starts to take its toll on their staffing abilities.
Tumor Boards: Valuable, but Tricky to Bill
The use of multidisciplinary tumor boards is effective when it comes to making decisions. Therefore, it has been adopted by most cancer care programs as an indicator of quality care. However, getting paid for the same may not be straightforward. There is a CPT code for the conference with an interdisciplinary group. However, the coverage of the procedure by all the payers is not always available, and even where coverage exists by some of the payers, the criteria are too strict.
Under these circumstances, it is very important that a professional oncology billing services team knows the coverage offered by all the payers. In cases where payers do offer coverage, it is important that the documentation of attendance, time, and discussion is adequate. On the other hand, for the payers who do not offer separate payment for it, the importance of the board will reflect in the form of better supported medical necessity of treatments and fewer denials during subsequent billing processes.
Care Coordination Has More Billing Pathways Than Most Practices Realize
Although tumor boards have been notoriously difficult to bill in claims-based systems, other forms of coordination services have become more claimable in recent years. There are now several codes for reimbursement for the time the clinical provider spends coordinating with the patient between office visits.
The chronic care management and principal care management codes are both designed for ongoing management of the patient with an illness, and cancer can be considered under certain conditions based on the structure of the program. The principal illness navigator codes, established by Medicare in recent years, are for navigators who guide a patient through the experience of being diagnosed with cancer, including the process of treatment planning and making appointments and referrals to community resources.
Each comes with its own criteria. Patient consent might require documentation. The amount of staff time has to be recorded in certain increments. There are different rules for billing provider and supervision per code. A business that starts a navigation program without this planning discovers that their claims have been rejected or even worse, reimbursed and then taken back.
Where Oncology Billing Services Expertise Changes the Outcome
The mere existence of the codes is straightforward knowledge. The challenge lies in developing an appropriate workflow and there is where external help pays its own way.
Experienced professionals start with the analysis of the activities currently being performed at the office. Nurse navigators, case managers, and doctors usually perform services that can be reimbursed but are unaware of that fact just because no one ever reviewed how those tasks correspond to the coding system. This audit often results in uncovering the services that were available but unnoticed.
Further on, billers develop a set of easy-to-do documentation procedures for clinicians. The time log, consent form, and care plans notes must not be elaborate but should be consistent. The navigator who records the time spent coordinating the patient’s imaging and authorization can make this activity reportable.
This is followed by payer rules. The coverage for these services varies significantly and changes over time. Expert oncology billing services that are multi-payer aware can help the practice take care of these variations. These teams are aware of which payers accept navigation codes, who require prior authorization, and who regularly deny particular combination of codes when filed on the same date.
The final step is follow up. It is natural for new codes to attract more denials as the payers themselves and even their reviewers are still getting familiar with the codes. Follow up helps recover payments that the busy front office may otherwise lose out on.
Compliance Cannot Be an Afterthought
These types of services tend to be documented in detail, making them vulnerable. Any billing that occurs because of coordination not clearly being achieved, or code stacking that involves similar procedures, is actual risk. An organization that runs too freely could end up owning money instead of collecting more.
A good oncology billing services partner always starts with compliance from the ground up. There will be systems to ensure that duplicate reporting has not occurred, and that thresholds have been reached before sending a bill. In doing so, the practice will stay protected and payment will be earned rightfully.
Final Thoughts
Collaboration of tumor boards and care coordination are two of the most valuable activities conducted in oncology practices and among the least consistently compensated. It requires knowledge, documentation, and persistence to close this gap, and this may prove too much for any team managing to run its oncology practice. Collaboration with professional oncology billing services makes it possible for these practices to recoup their investments in terms of money and effort.
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