In the field of oncology, patient care rightly takes center stage. But behind the scenes lies the financial well-being of an oncology practice, the driving force behind all this. The intricacies involved in cancer treatment put a huge burden on an oncology practice’s revenue cycle management (RCM). A poorly managed process can have a bearing on resource utilization, stifle growth, and finally, take attention away from patient outcomes.
Streamlining end-to-end revenue cycle management is a business necessity that guarantees sustainability and the capacity to keep delivering the highest quality of care. For most practices, charting this financial maze is like walking in quicksand. The good news is that through a focused strategy, you can re-engineer your RCM from a stressful afterthought to a streamlined, effective, and resilient foundation of your practice.
The Front End: Your First Line of Defense
The revenue cycle starts when a patient schedules an appointment, not when a claim is filed. An astonishing percentage of downstream problems, from claim denial to bad debt, can be attributed to errors at the front end. Building this first stage is essential to optimize your revenue cycle management.
Begin with strong patient registration and insurance verification. This might seem simple, but it’s an arena where mistakes often happen. Employees need to be thoroughly trained to obtain correct demographic and insurance data.
Active, real-time eligibility and benefits verification is vital. This verification ensures the patient’s coverage is active and discloses essential information about their plan, including deductibles, co-payments, and co-insurance obligations. Being aware of this information in advance ensures transparent financial discussions with patients right from the start.
In addition, oncology is full of prior authorizations. The administrative hassle involved in getting pre-approval for chemotherapy medications, radiation, and high-end imaging is a key challenge for most practices. An exclusive system that works studiously to handle prior authorizations is an absolute necessity.
Coding and Billing Precision
Oncology billing is a specialty in and of itself with an intricate matrix of diagnosis codes (ICD-10), procedures (CPT), and unique drugs (HCPCS). Because oncology drugs and services are so expensive, even a small coding mistake can cause a substantial denial or underpayment.
Expert coding skills are not an option. Your coding staff needs to be familiar with the subtleties of oncology, such as the appropriate use of modifiers, correct coding of drug administration, and the documentation that will substantiate medical necessity.
Daily training and keeping up with the constant changes in coding guidelines and payer policies are necessary. The rate of claims is a direct reflection of a well-oiled revenue cycle management process, with quicker payments and fewer dollars spent in rework.
Financial Transparency
The increasing popularity of high-deductible health plans has burdened patients with more of the monetary responsibility. For oncology, where out-of-pocket expenses can be excessive, this presents a new category of problem commonly termed “financial toxicity.” Treating it ahead of time is wise from an RCM angle.
Having a patient financial counseling program in place can make all the difference in your revenue cycle management strategy. A financial counselor can sit down with the patient prior to treatment and review their insurance benefits, provide an estimate of how much they will pay out-of-pocket, and address payment plans. Translucency here helps to control patient expectations, as well as ease the fear that accompanies financial unpredictability.
The counselors can also help the patients to recognize and enroll in financial aid programs, including manufacturer copay cards, foundation grants, and others. By guiding the patients through these resources, you not only relieve them of their financial burden but also maximize the chances that the practice will get paid for services provided.
Denial Management and Analytics
Even with optimal front-end and billing operations, denials may happen. The difference lies in how you handle them. A passive strategy of writing off or appealing denials randomly is a recipe for revenue loss.
A strong denial management process includes tracking, analyzing, and appealing denied claims systematically. The initial step is to recognize the underlying reason behind every denial. By categorizing and analyzing denial trends, one can determine patterns and fix the underlying issues to avoid repeated denials in the future.
Tapping the potential of data and analytics is the last piece of the puzzle. Your practice management system has a treasure trove of data. Keeping an eye on critical performance indicators like days in accounts receivable (A/R) and denial rate gives you a good picture of how healthy your revenue cycle is. These indicators enable you to benchmark your performance, recognize areas of improvement, and make informed decisions to tweak your RCM strategy.
Ultimately, optimizing revenue cycle management within an oncology practice is an ongoing process, not a single solution. It demands an overarching vision that harmonizes people, processes, and technology. By strengthening your front-end processes, maintaining coding accuracy, adopting patient financial transparency, assiduously managing the back end, and even outsourcing to specialists when needed, you build a strong financial foundation. This enables you to do what you do best: give top-notch, life-saving care to your patients.
