Oncology & Hematology Coding Alert

Make your EHR work for you at every stage of the revenue cycle.

Who hasn’t experienced denial distress at some time or another? But who bears responsibility when it happens? What if everyone in your practice or facility, from clinical staff through to the front desk and the billing department played a part in the revenue cycle?

The result, according to Rita Genovese CPC, PCS, director of revenue cycle and business operations at MD Anderson at Cooper Camden, New Jersey, in her HEALTHCON 2022 presentation, “The Magical World of Oncology Billing: Finding Your Happy Place,” would be a more efficient workflow and fewer denials.

Here is her expert advice on how to avoid the most common denials using a team-based approach to the revenue cycle.

Get Off to a Good Start With Pre-Eligibility Specialists

“One of the best ways to decrease denials in large departments within institutions, and even in smaller practices, is to have people dedicated to pre-verification or pre-eligibility,” according to Genovese. A pre-eligibility specialist or team will validate everything within the patient’s information at the very start of the patient’s treatment.

Importantly, not only will a specialist in this area avoid problems down the road with the patient’s insurance, and help the patient negotiate any financial barriers to their treatment, but a pre-verification specialist will also be able to notify other key members of the team — authorization specialists — who can head off any complicated authorization denials before they begin.

Streamline Your Workflow to Avoid Authorization Denials

Authorization denial is perhaps the number one denial that’s difficult to reduce, “because insurance companies don’t retro back,” Genovese pointed out. She suggests that your specialist or team authorize all the treatments at the time of ordering. “Once the clinician orders the regimen in the EHR [electronic health record], it will then populate into a work queue that has been created for the authorization team. This includes dates, so the authorization team knows when the patient has to have the treatment by,” Genovese advised.

The authorization team needs a great deal of training, though again, a well-constructed EHR will help streamline the process. “We’ve created templates for our providers, especially for when chemotherapy is involved, where the authorization team can go to find information they need, such as the history of past treatment, including failed treatment,” Genovese noted.

“This means the team not only needs to have knowledge of pharmaceuticals and payer policy, but they also need to know diagnosis and CPT^® coding, because they need to know the routes, the times, the premeds, the hydration, and so on.”

The practice should allocate an authorization team for all treatment areas. For radiation oncology precertification, the authorization team needs to work with both dosimetrists and therapists, while for surgical preauthorization, the team needs to understand the procedures and anatomical locations. “Splitting out into teams and having each team become specialists in their chosen area has really helped, but there’s a lot of communication between the auth teams and the providers,” Genovese advised. This is especially true for Medicare, whose primary concern is medical necessity. To decrease those denials, “the team needs to ensure that the diagnosis and the order support the regimen,” Genovese cautioned.

Follow This Chemo Authorization Workflow Example

The standard process for chemo authorization provides a good example for authorization processes across treatment modalities and looks something like this:

• Care team completes a chemo review request electronically
• Revenue cycle team prepares the authorization and submits medical records, imaging, and labs to the payer electronically for authorization
• Authorization request approved in the patient’s EHR
• Approved treatments routed to chemo schedulers’ work queue
• Scheduler reviews with infusion team, then makes patient’s appointment

Importantly, in this workflow model, nothing is ever scheduled prior to authorization, as payers will not backdate authorizations, which can create an even greater denial headache.

Team Up to Deal With New Drug Therapy Denials

Another kind of denial — payer refusals of new drug therapies — is also best handled in a team environment. Here’s how that works.

Step 1: A provider brings forward a new pharmaceutical therapy request to a centralized committee consisting of a pharmacist and the revenue cycle team. The team reviews such things as cost, efficacy, provider policies, and other pertinent issues.

Step 2: Once all factors have been considered, the team formulates a recommendation that is sent back to senior leadership for adoption consideration.

Step 3: If the drug is adopted, then an education process begins. Nursing is informed of possible allergic reactions, how the new drug can be infused, and so on. Revenue cycle also gets involved again at this point, as they monitor payment by payer.

By looking at all the angles — efficacy, cost, insurance policies, and so on — the team can make an educated decision before adopting a new therapy, eliminating problems down the road.

Reconsider Your Approach to Reauthorization Denials

The simplest way to avoid this kind of denial is to build a trigger into the authorization work queue within the EHR that provides an alert 14 days prior to the authorization expiration date. This gives the authorization team plenty of time to contact the provider regarding patient status and, if treatment is to be continued, initiate the reauthorization.

Surprisingly, though, patient weight loss can trigger a reauthorization because it can change treatment frequency or dosing and will require reauthorization by a payer. This means someone on the team needs to review a patient’s clinical data daily, and if there’s a change in the patient’s weight, dose, or treatment frequency, the reauthorization staff member needs to alert the clinical team to initiate a new chemotherapy review, triggering reauthorization to be added to the workflow.

The Bottom Line: Teamwork Makes the Dream Work

The investment required in implementing such a team approach to avoiding denials may seem daunting, but “implementing strong processes and providing training for each individual who plays a part in the workflow will save both time and money down the line,” advises Leah Fuller, CPC, COC, senior consultant, Pinnacle Enterprise Risk Consulting Services LLC, Centennial, Colorado.