Transcript Managing Cancer Practices in Whitewater Times

Managing Cancer Practices in
Whitewater Times
ANCO Membership
March, 2008
Many Thanks
To
RemitDATA
for the cool statistics
herein
Areas for Improvement
Managing Managed Care
 Managing the Top Line
 Managing the Cash Cycle
 Managing Efficiency
 Summing It All Up

Get Over It!
Ability to Ne gotia te With MC Pa y e rs
25
20
15
S eries 1
10
5
0
O ne
T wo
T hre e
F our
F ive
S ix
Self Score
S ev en
E ight
N ine
T en
From my survey of 120 practice managers in 2006 who rated
themselves on a scale 1-10 in terms of negotiating skills.
Think You Can’t Negotiate?
Primary Pay ers only
Per Unit
Allowed amounts by procedure
HCPC
90765
90767
96413
99214
99245
75th
105.41
56.44
269.00
109.78
292.59
50th
83.46
47.78
199.00
95.87
245.96
25th
71.53
40.00
161.00
84.68
213.93
Average
92.47
52.14
214.82
97.25
253.48
Per Unit
Data included is for all claims with a Check Date between 10/1/2007 and
HCPC
J0640
J0881
J0885
J9265
J9310
75th
Percentile
3.75
5.49
15.00
165.82
555.40
50th
Percentile
2.31
3.92
12.01
55.00
517.36
25th
Percentile
1.12
3.05
10.65
15.12
499.13
Medicare
$0.86
$2.89
$8.96
$13.58
$508.66
Source: RemitDATA ERA allowed charge data of 1500+ Oncologists across U.S.
© RemitDATA All Rights Reserved
Think You Can’t Negotiate?

CPT Codes: Range of Allowed Payments
Compared to Medicare
Allowed amounts by procedure
90th
Procedure
75th
50th
25th
10th
Average
Medicare
% Medicare
RVUs
90765
1.97
$122.41
$105.64
$83.46
$71.53
$64.00
$92.55
$73.89
125%
90767
1.02
$133.96
$87.72
$52.70
$42.51
$36.75
$72.17
$38.09
189%
96413
4.27
$319.30
$269.00
$199.00
$161.00
$146.58
$215.06
$161.49
133%
99214
2.53
$118.09
$109.78
$95.87
$84.68
$69.83
$97.32
$89.89
108%
99245
6.25
$310.00
$292.59
$245.96
$213.93
$192.62
$253.48
$220.90
115%
Source: RemitDATA ERA allowed charge data of 1500+ Oncologists across U.S.
© RemitDATA All Rights Reserved
Think You Can’t Negotiate?

Conversion Factors (Medicare = $38.0870)
Procedure RVUs
90th
75th
50th
25th
10th
Average
90765
1.97
$62.14
$53.62
$42.37
$36.31
$32.49
$46.98
90767
1.02
$131.33
$86.00
$51.67
$41.68
$36.03
$70.76
96413
4.27
$74.78
$63.00
$46.60
$37.70
$34.33
$50.37
99214
2.53
$46.68
$43.39
$37.89
$33.47
$27.60
$38.47
99245
6.25
$49.60
$46.81
$39.35
$34.23
$30.82
$40.56
Source: RemitDATA ERA allowed charge data of 1500+ Oncologists across U.S.
© RemitDATA All Rights Reserved
Think You Can’t Negotiate?
Per Unit
Data included is for all claims with a Check Date between 10/1/2007 and
HCPC
J0640
J0881
J0885
J9265
J9310
75th
Percentile
3.75
5.49
15.00
165.82
555.40
50th
Percentile
2.31
3.92
12.01
55.00
517.36
25th
Percentile
1.12
3.05
10.65
15.12
499.13
Medicare
$0.86
$2.89
$8.96
$13.58
$508.66
Source: RemitDATA ERA allowed charge data of 1500+ Oncologists across U.S.
© RemitDATA All Rights Reserved
.
Managing Managed Care

Basics
Know your RBRVS
 Know your drug payment methodologies
 Know your patient profile
 Know your “walk away”

RBRVS Basics

3 inputs go into the total RVUs




Work = Face-to-face physician time, plus intensity of
work
Practice expense = practice expense relative to other
procedures (with no intensity of expense)
Malpractice insurance costs (< 5%) = malpractice
risk
Equation is ((W*WGPCI)+(PE*PEGPCI)+(M*MGPCI))
times the conversion factor = Fee Schedule Allowable for
all codes except labs and drugs
Know YOUR RBRVS

How are managed care companies using
RBRVS?
Not! Using a percentage of Medicare.
 Using a different conversion factor
 Using no GPCIs
 Using old fee schedules--good and bad

RBRVS Talking Points




The Medicare conversion factor is a governmental aberration that
has nothing to do with economic conditions.
RBRVS was developed for procedural specialties. It does not work
for specialties who have indirect physician participation.
Most drug administration code payments have nothing to do with
cost. Many actual costs have never been captured by anyone.
Most private payers pay hospital outpatient services based on
charges. It is cheaper for patients to stay in the community setting.
Know your drug payment
methodologies

What are they using?
Average Selling Price, plus
 Average Wholesale Price

• Red Book
• Orange Book
• Medispan
Wholesale Acquisition Cost
 Widely Available Market Price
 Average Manufacturers Price

Managed Care Bottom Line

Medicare RBRVS



Drug payment



What is the the net allowable that is paid by
Medicare versus the MCO?
How does that translate into a conversion factor?
More later…
Figure out whether their methodology meets their
contract language
Ascertain by regimen what tumor types are
“underwater” as appropriate using PROTOCOL
ANALYZER®
Can you ask for more???
Know Your Patient Profile

Develop statistics for the following:
Patients in their plan who are out of
treatment and are alive per year.
 Hospitalizations/ patient and per patient
aggregated per thousand for your practice
 Average back to work time
 Average payer cost per patient; per tumor
type


Compare your data to national norms
Patient Profile

Helpful national statistics
Discharges/1000 = 117.44*
 Average inpatient LOS per cancer patient =
6.8 days*
 # of ER visits per 100 persons =39.6*
 Average days missed for young women with
breast cancer in one study = 29 days within
three months of initial treatment**

*National Committee on Health Statistics
** “Quality of Life Among Young Woman With Breast Cancer”; Journal of Clinical Oncology, Vol 23, No
15 (May 20), 2005: pp. 3322-3330 © 2005 American Society of Clinical Oncology.
Know Your Walk Away

Number of patients in treatment




Past net reimbursement
Projected annual net reimbursement
% rise or fall
What is their net conversion factor?




Net collected service reimbursement divided by total
relative values = CCF
Net direct cost per paid RVU = DCCF
CCF-DCCF = Profitability per RVU
Can add a “fudge factor” for hassle factor, e.g. preauthorization, slow payment, referrals
Know Your Walk Away

Drugs
“Underwater” or net profit after co-pays
 Regimen-by-regimen comparison


Public relations
Contract confidentiality
 Coordination of patient benefits
 Out of network

Managing the Top Line

Integration

Backwards
• Hospital-Physician networks
• Hospital-Physician Cancer Care Networking
• Cancer Care Hospital formation? Physician-owned?

Forwards
•
•
•
•
•
•
•
Radiation
Radiology
Pharmacy
Gyn-Onc
Ped-Onc
Hospitalists
Surgery: Ports, PICCs, Biopsies
Managing the Top Line

Can you reset your fees?

National Ranges® from multiple public and
private databases.
• 90767 = Range $39-86
• 90772 = Range $29-42
• 96413 = Range $230-303
® MAG Mutual Healthcare Solutions, Inc. All Rights Reserved
Managing the Top Line

Billing for all allowable services
Smoking Cessation
 PQRI
 Discharge > 30 minutes
 Missed Appointments
 Care Plan Oversight Services
 Home Health Certification

Tobacco Cessation
Getting Paid



Effective March 22, 2005, Medicare covers tobacco
cessation counseling for patients who smoke and have
a tobacco-related disease or whose therapy is affected
by tobacco use.
Effective January 2006, Medicare's prescription drug
benefit covers smoking cessation treatments prescribed
by a physician.
Carriers are supposed to start paying new codes
January 1, 2008.
Smoking Cessation
Billing for tobacco cessation counseling
CPT codes



99406 (was G0375): Smoking and tobacco use
cessation visit; intermediate; counseling for 3-10
minutes
99407 (was G0376): counseling for more than 10
minutes
Can be used for all payers now…
Smoking Cessation
Billing for tobacco cessation counseling
CPT codes




8 visits annually allowed in 12 month period (4 sessions
per attempt).
Counseling < 3 min covered under E&M code.
Can have an appropriate E/M service on same day, use
modifier -25 as long as there is no duplication of
therapy.
Face-to-face counseling time can be “incident to”.
Tobacco Cessation
Billing for tobacco cessation counseling
ICD-9-CM codes





305.1: Tobacco Use Disorder or
V15.82: History of Tobacco Use
Provide other clinically relevant diagnosis code, such as
cough, lung cancer, chemotherapy, etc. that is
adversely impacted by smoking.
Document time spent counseling for tobacco cessation
There are PQRI measures that go with this…
Tobacco Cessation


99406, Intermediate
 WRVU = 0.32
 Fee = $12.19
99407, Intensive
 WRVU = 0.65
 Fee = $23.99
To PQRI or Not to PQRI?

What is PQRI?



It is the Medicare Physician Quality Reporting Initiative. In plain
English, CMS will pay you a bonus to report what they want you to
report.
It is a strictly voluntary program in 2008. It is reported by National
Provider Identification Number. According to my estimates about 4050% of Medical oncologists are participating in 2008. This varies
geographically.
There are 119 measures to choose from and they can be found at
http://cms.hhs.gov/pqri
•
•
•
Use measures that apply most your mix of services.
Use those that might help you reach a reporting or quality goal for your
group.
Know that every group is different in terms of what measures are
applicable to them. All measures should be reviewed with providers.
Physician Quality Reporting
Initiative (PQRI)

Bonus Payment

Participating eligible professionals who successfully report may earn
an approximate 1.5% bonus, subject to a cap
•
•


To earn it, each provider must report 80% of at least three measures.
Providers can report fewer measures, but this will be subject to
statistical validity testing.
1.5% bonus calculation based on total allowed charges (the sum of all
billed allowables) during the reporting period for professional services
billed under the Physician Fee Schedule. This does not include
laboratory services or drugs. This bonus will not be determined until
the end of 2008, but it is expected to be 1.5%.
Bonus payments will be made in a lump sum in mid-2009 to the
holder of record of the Taxpayer Identification Number (TIN)
No Medicare Advantage patients will be included in your calculation.
Physician Quality Reporting
Initiative (PQRI)

Bonus Payment Cap


A Cap may apply when relatively few instances of quality measures apply
and are reported and will be applied to each NPI. You will be paid the
lesser of the cap amount or your 1.5%. This is why frequency of
reporting is important.
Cap calculation =
(Individual’s instances of reporting quality data) X
(300%) X (National average per measure payment amount, which is not
known until the following year)
National average per measure payment amount =
(National charges associated with quality measures) /
(National instances of reporting)

Example is if you had 100 incidents of reporting x 300% = 300 and the
hypothetical national payment average amount was $100, the CAP for
you would be $30,000. If your 1.5% allowed revenue exceeds $30,000,
you would be paid the CAP.
PQRI Participation--Good or
Bad?

Hypothetical example of a Hem-Onc practice without Radiation or other ancillary
services…
 Six-physician Oncology Practice, 4.0 NPs
 $22.7 million in total allowed charges projected for 2007
• 50% Medicare
• $2,200,000 = Procedures (mostly drug administration)
• $3,100,000 = Evaluation & Management
• $17,400,000 = Drugs
• No lab in office
• Does not account for patient portions
 1.5% of one year of procedures = approximately $40,000 if they all report and
exceed the CAP.

BUT, if your practice has procedure-based services, this can be much larger…
Discharge Over 30 minutes






Must be the discharging MD
30 minutes of FLOOR time; must be
documented in the medical record
Billed 30,067 times in 2005 by Hem-Onc’s with
5% denial rate (less than average)
22% of 2005 discharges billed by Hem-Onc’s
2008 RVUs = 2.67
Average Medicare Reimbursement = $92.93
Medicare: Missed Appointments

Transmittal 1279, CR 5613



May charge Medicare patients as long as you charge all
patients equally at the same amount for missed appointments,
unless contractually you are unable to do so (Medicaid).
May not charge for a specific item or service but for a
‘missed business opportunity’.
May not charge these to Medicare, but to the patient directly.
Care Plan Oversight Services
(Medicare)





Complex billing rules with heavy denial rate and
audit follow-up.
G0181, Home Healthcare Oversight, 30
minutes per month= $103.98
G0182, Hospice Oversight, 30 minutes per
month = $107.79
G0181 billed 1253 times by Hem-Onc’s in 2004
with 25% denial rate.
G0182 billed 2313 times by Hem-Onc’s with
33% denial rate
Care Plan Oversight Medicare

Billing Requirements (Section 180.1, Chapter
12, Claims Processing Manual)





Chapter 15, Benefits Policy Manual are met; may not
be billed ‘incident to’
No other services may be billed on the same claim
May only bill at the end of the month in which
services were rendered.
Bill for one unit of service
Must have the provider number of the HHA or
hospice.
Care Plan Oversight (Private)

99374-99380
Start at 15 minutes
 Includes Nursing Facilities, which Medicare
does not.
 BUT, physician involvement and
documentation requirements are steep.

Home Health Cert/ Re-cert
G0179-G0180: Billed 2541 and 5227
times in 2004; denied 12% and 7%
respectively.
 G0179: Home Health Re-certification =
1.22 RVUs = $44.56
 G0180: Home Health Certification = 1.61
= $58.27

Home Health Cert/ Re-Cert
Code G0180 can only be billed when the
patient has not received Medicarecovered home health services for at least
60 days.
 Code G0179 can only be billed when the
patient has had services for at least 60
days (one certification period) and is
reported every 60 days.

Keeping Your Revenue

Fraud Issues


Benefit Integrity Unit Screening
Qui Tam
•
•
•
•
•
•

Place of Service
“Incident to”
Free drug billing
Billing for non-delivered or undocumented services
Billing under wrong provider #
Knowingly billing the wrong codes to maximize revenue
Kick-backs
Keeping Your Revenue

Recovery Audit Contractors
Documentation of/ accounting for WASTE
 Unbundling/Modifier -59
 Modifier -25
 38221/38220-59
 ESA dosing
 Other drug dosing
 Odd coding

Medicare: Drug Waste

Medicare does not pay for drug waste, unless it is
administered to a patient.

"CMS will cover the amount of drug necessary for the patient's condition. If a portion
must be discarded after the patient is treated, Medicare will cover the discarded
drug along with the amount administered." This is published in the Medicare Claims
Processing Manual, Chapter 17 – Drugs and Biologicals (section 40-Discarded
Drugs and Biologicals).
While that is not at all clearly stated in the waste section, I refer you to the Medicare
Benefit Policy Manual, Chapter 15, Section 20:
 " Part B expenses for items and services ...are considered to be incurred the
day the beneficiary RECEIVED the item or service, regardless of when it was
paid for or ordered..."
And, Medicare Benefit Policy Manual, Chapter 15, Section 30:
 "The physician must render the service for it to be covered."


Drug Wastage

Empire New York Part B

Recent reviews by Medicare contractors indicate that providers are not adequately documenting,
in their medical records, the provision and administration of drugs in the office setting. Empire
Medicare Services expects that providers adhere to the following guidelines:






Physicians and non-physician providers should enter the drug ordered in their plan of care for the
encounter.
The dose and route should be included along with the name of the drug.
The encounter should be dated and signed in the medical record (or electronically if using EMR).
The person actually administering the drug should enter into the record that he/she administered the drug,
include the dose, route, and site of administration, and sign/date that entry.
It is recommended that providers include the drug lot number when documenting the administration of the
drug.
If the drug was administered by the ordering provider, it would be sufficient for that person to enter “given”
next to the order in the plan of care (and also include the site of administration and lot number).
Drug Wastage

Empire New York Part B (Cont’d)






A provider may indicate that the drug will be administered over a number of dates in the future, in a single
plan of care. However, each subsequent administration of the drug must be separately documented as
noted above.
Signatures should be legible (you may want to print your name under the signature, if necessary).
If the full amount of a single-use vial is not administered, the provider or staff administering the drug should
enter a note in the patient’s medical record indicating the amount not administered (discarded) as wastage.
These guidelines are intended to document the provision and administration of drugs that are covered
under the Medicare “incident to” benefit (the drug is administered by the physician/non-physician provider
or staff in the office). Use of these documentation guidelines will not extend Medicare coverage to any drug
not otherwise covered (e.g., drugs that are usually self-administered, drugs that are not Food and Drug
Administration (FDA) approved, drugs provided for indications that are not considered medically
necessary, etc.). Drugs provided in the physician office may not be billed to Medicare unless they are also
administered by or incident to the same physician/group.
Furthermore, providers should not bill Medicare for visits (Evaluation & Management (E&M) services)
when the purpose of the encounter was for the administration of the drug.
Providers should retain drug invoice records to document the purchase of the drug, if requested by a
Medicare contractor
Keeping Your Revenue

Look at the updates each quarter to ASP from prior
quarters. It happens each quarter and you can go back
and get the $$.


http://www.cms.hhs.gov/McrPartBDrugAvgSalesPrice/01b_200
7aspfiles.asp#TopOfPage
Can amount to a great deal of $$$
QuickTime™ and a
TIFF (LZW) decompressor
are needed to see this picture.
Keeping Your Revenue

Private Payers
Do not use Medicare parameters for ESAs, if
your clinicians do not agree with them.
 Get as much verified up front as possible

• Codes
• Co-pays/ Coinsurance
• Referrals or authorizations necessary

Match actual reimbursements with contract
terms.
Accounts Receivable/ Cash
Cycle

What is the cash cycle?
Cash incoming from Receivables, Interest,
Dividends, honoraria, and revenue from
clinical trials
 Cash outgoing for ongoing costs including
drugs, payroll, rent, utilities, and other
ongoing costs.

Aged Cash Report

From 1500+ Community Oncologists:
•
•
•
•
•
•
•
0-30 days = 80.3%
31-60 days =12.9%
61-90 days = 2.6%
91-120 days = 1.2%
121-150 days = 0.7%
151-180 days = 0.5%
> 180 days = 1.8%
• AVERAGE DSO = 32 days
Source: RemitDATA ERA allowed charge data of 1500+ Oncologists across U.S.
© RemitDATA All Rights Reserved.
Denial Reasons
National Statistics from CashRetriever

C urrent as o f 1/28/08 ...
Denia l
Code
1
2
3
4
5
6
7
8
9
10
D escription
18
Den ie d-d u plicated cla im/se rvice
B1 3
42
23
16
22
125
96
119
27
Den ie d-previo us ly paid
Den ie d-chgs exceed fee sched ule or allowa ble
P m t ad jus te d-paid b y a nothe r p aye r
Den ie d-lack o f neede d inform ation
P m t ad jus te d-co vere d b ya noth er pa yer
P m t ad jus te d-submis s ion/billing error
Non co vered charg es
Ben efits excee ded
Den ie d-expe nses in curred a fte r covera g e
#
Rem its
Denie d
A mount
1 5 6 ,4 4 1
$ 6 3 5 ,428 ,07 1
5 7 ,1 7 8
6 8 ,1 4 9
8 9 ,8 7 6
5 5 ,3 6 2
5 3 ,4 6 2
1 2 ,5 3 1
6 0 ,2 4 8
1 2 ,5 1 1
4 3 ,7 8 7
$ 4 1 2 ,746 ,85 4
$ 3 1 7 ,812 ,52 1
$ 2 5 9 ,859 ,56 1
$ 2 2 8 ,030 ,93 0
$ 2 1 7 ,472 ,43 9
$ 1 5 3 ,920 ,85 2
$ 1 3 7 ,100 ,63 6
$ 8 9 ,3 16,829
$ 8 0 ,2 81,087
Source: http://www.cashretriever.com/home/835denialstatistics.html
Denial Reasons

From RemitDATA (all Specialties)
All payers = top 10 Reasons (CODE) for ALL data
transaction_count
1516196
code
CO18
OA109
PR204
OA18
CO176
CO97
CO50
CO150
PR96
COB15
CO16
count
%
230951
131330
71133
67236
66412
66119
63677
59637
50941
38260
35160
15.23
8.66
4.69
4.43
4.38
4.36
4.20
3.93
3.36
2.52
2.32
description
Duplicate claim/service.
Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor.
T his service/equipment/drug is not covered under the patient’s current benefit plan
Duplicate claim/service.
Payment denied because the prescription is not current.
Payment adjusted because the benefit for this service is included in the payment/allowance for another service/p
T hese are non-covered services because this is not deemed a `medical necessity' by the payer.
Payment adjusted because the payer deems the information submitted does not support this level of service.
Non-covered charge(s).
Payment adjusted because this service/procedure requires that a qualifying service/procedure be received and co
Claim/service lacks information which is needed for adjudication.
Source: RemitDATA ERA allowed charge data of 1500+ Oncologists across U.S.
© RemitDATA All Rights Reserved
Denial Reasons

From RemitDATA for ONCOLOGY Only
All Payers = top 10 Reasons (CODE) for ONC specialty
transaction_count
405450
code
CO97
CO18
OA18
PI97
CO45
COB15
PR16
PR27
OA23
CO16
PR96
count
%
description
59222
14.61 Payment adjusted because the benefit for this service is included in another service.
55006
13.57 Duplicate claim/service.
38817
9.57 Duplicate claim/service.
24676
6.09 Payment adjusted because the benefit for this service is included in the payment/allowance for another service/proce
18466
4.55 Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.
15311
3.78 Payment adjusted because this service/procedure requires that a qualifying service/procedure be received and covere
11331
2.79 Claim/service lacks information which is needed for adjudication.
11058
2.73 Expenses incurred after coverage terminated.
9443
2.33 Payment adjusted due to the impact of prior payer(s) adjudication including payments and/or adjustments.
8468
2.09 Claim/service lacks information which is needed for adjudication.
8269
2.04 Non-covered charge(s).
Source: RemitDATA ERA allowed charge data of 1500+ Oncologists across U.S.
© RemitDATA All Rights Reserved
Denials

Duplicate claims are dangerous
From Noridian Part B Medicare
 ”If more than one claim is submitted for the same
item for the same date of service, the second claim
will be denied as duplicate. Submitting duplicate
claims:
1.
2.
3.
May delay payment;
Could cause you to be identified as an
abusive biller; or
May result in an investigation for fraud if a
pattern of duplicate billing is identified.”
Denials

Duplicate Claims are dangerous for other
reasons
Inflated A/R
 Inflated cash projections
 Poor utilization of staff in terms of
investigation and write-off’s
 Opportunity cost of not working real denials

Denials

Duplicate Claim Resolution (TRAILBLAZER)




Step 1: Please allow Medicare 30 days from receipt date to process the claim for payment.
If the provider is not enrolled in Electronic Funds Transfer (EFT), an additional seven to 10
days should be added for mail time. Although electronic claims may be processed in as few
as 14 days, it could take as long as 30 days to process the claim.
Step 2: The provider should call the Carrier IVR to check claim status. If Medicare has not
received the claim and enough time has passed after filing the claim for Medicare to have
received it, the provider should re-file a new claim. If the IVR indicates that Medicare has
received the claim and it is in process, the provider should allow time for the claim to
continue processing and wait for the Remittance Advice (RA).
Step 3: Many times providers overlook zero-pay RAs due to the allowed amount being
applied to the patient’s deductible. Providers should pay special attention to zero- pay RAs
in order to determine if the claim should actually be re-filed to Medicare.
Step 4: If the same procedures are performed multiple times on the same day, the provider
may refer to specific claims filing guidelines for multiple servicing and/or use of any
appropriate modifiers. POE may be contacted for help with filing these services.
Denials

Service included in another service that
has already been adjudicated (C097)

Unbundling items like fluids, supplies, etc.
• Is it worth it to keep writing these things off?
• How much are you paid on average?

Code edits--increased uptake can lead to
audits.
Denials

Qualifying service not
received/adjudicated (COB15)

Remember that add-on codes need to be on
the same claim with qualifying service:
• Add on codes: 90761, 90766, 90767, 90768,
90775, 96411, 96415, 96417
• Make sure they are paired with the CPT rule
codes. Example: 90768 with 90765, 90766,
96413, 96415, 96416
Denials


Missing/Incomplete/Invalid Group Practice Information (CO16,PR16) Description The information reported in Item 33 of the
CMS-1500 claim form is not correct or is missing. The provider of
service must enter the provider of service/supplier’s billing name,
address, ZIP code and telephone number in Item 33.
Resolution Providers should make sure the information in Item 33
of the CMS-1500 claim form is correct. If the claim is filed as paper,
Item 33 is the proper place to report this information. If the claim is
filed electronically, the completion of certain loops and segments is
necessary.
Denials

Claims billed to wrong payers


Patient should be asked each time they appear if
their insurance has changed
New Medicare patients should be asked if they
• Still have insurance through their employer
• Have “another” Medicare plan

Patients, unless their plan contract specifies
otherwise, should sign a statement stating that they
are liable if they do not update insurance information,
if it changes.
Denials

Problems due to poor patient intake
Lack of referral or authorization
 Poor knowledge of policy limits such as
payment ceiling leading to exhaustion of
benefits
 No information on payment cap or
catastrophic coverage leads to missing
payment opportunities

Common Coding Errors in
Medical Oncology
Two “initial” codes
 Billing an add-on code (e.g. 90766)
without a qualifying service
 Billing 96523 with other services
 Billing of concurrent hydration
 Hydration versus therapeutic infusions
 Consultations
 Incorrect diagnosis with drug

Cash outlays

What can you fix?




Payment terms that lead to constant cash shortfalls.
Interest rates on charge cards, loans, lines of credit,
and other interest-bearing items that will change as
interest rates go down.
Rent and office leases will soon become negotiable
as the economy inspires a “buyer’s market.
Salary raises that are automatic as opposed to
incentive-based.
Efficiency

Do benchmarks apply to you?
Automation
 Access to capital
 Space efficiencies/inefficiencies
 Skill set of clinical staff
 Access to mid-levels
 Cross-training and staff coverage
 Severity index of patients

Benchmarks

Levels
Level I--Compare yourself to yourself over a
time period
 Level II--Compare yourself to your ‘peers’ in
the oncology community
 Level III--Custom benchmarks for you or for
peer cohort(s)

Efficiency

Internal measures (Level 1)

Financial
•
•
•
•
•
•
•
•
•
Cost of Goods Sold (Direct Revenue-Direct Expense)
Net Revenue/ FTE
Cost/ FTE
Net Advantage/ FTE
Revenue/ Patient Encounter
Cost/ Patient Encounter
Net Advantage/ Patient Encounter
Net Advantage/ Hour of Operation
Net Drug Reimbursement plus Rebates/ Drug Cost
FTE = 40 hours per week or 2080 hours per year
Efficiency

Internal Measures (Level I)

Physician Productivity
•
•
•
•
•
•
•
•
Visits/ Physician
New Patients/ Physician
E/M Net Reimbursement/ Physician
RVUs/ Physician*
FTEs/ Physician
Treatment Chairs/ Physician
RN FTE/ Physician
Net Advantage/ Physician
Efficiency

Internal Measures (Level 1)

Nursing
•
•
•
•
•
•
Chair Turn
Patient Encounters/ FTE of Nursing
Drug Administration* Net Revenue/ Chair
Drug Administration Net Revenue/ FTE Nursing
Net Benefit**/ FTE of Nursing
Drug Admin Patients/ RN
*Includes drugs and admin
**Drug admin net revenue-direct nursing cost (S+B)
Efficiency

Internal Measures

Billing (FTEs are all billing)
•
•
•
•
•
$ over 60 days
$ in AR/ FTE
Cash Collections per FTE
Patient Balances per FTE
Denied dollar per FTE
Efficiency

Benchmarks: Hem-Onc (Level II)

Physician Productivity (Mean Value)
• New Patients/ FTE physician/yr = 300 (342 with NPPs)
• Established Patients/ FTE physician/yr =3481

Staffing (Mean Value)
• FTE/ Staff Physician = 7.3 (6.6 for multi-specialty)
• FTE Nurses Administering Chemo/ FTE MD = 1.7
• FTE Mid-Levels/ FTE MD = 0.7
Source: Journal of Oncology Practice; Volume 3, Issue 1, January 2007: Benchmarking
Practice Operations; Acksin, J, Barr, T. and Elaine Towle
Efficiency

Benchmarks (Level II)

Resource Utilization (Average or Mean)
•
•
•
•
Treatment Chairs /FTE Physician = 5.7
Treatment Chairs/ FTE Chemo Nurse = 3.8
# of Patients/ Chemo Chair/ Working Day = 1.3
Patients/ FTE Nurse/ Working Day = 2.1
Source: Journal of Oncology Practice; Volume 3, Issue 1, January 2007: Benchmarking
Practice Operations; Acksin, J, Barr, T. and Elaine Towle
Efficiency
The Codemistress Treasure Trove of
Efficiency Tools

Benchmarking


Oncology Circle
http://www.oncomet.com/OncologyCircle/Oncolo
gyCircleHome.aspx
Encoders--All the codes you ever want to know
and all the rules/ limitations around them.



DecisionCoder®: www.decisioncoder.com/
Encoder Pro Professional
http://www.medicalcodingbooks.com/codingsoft
ware/
Flash Coder http://www.flashcode.com/
Treasure Trove of Efficiency Tools



Drug Coding and Pricing
 Reimbursement Codes.com
http://www.rjhealthsystems.com/reimbcode.htm
Fees--Great information about setting fees and coding rules too!
One of my favorites for twenty years.
 MagMutual www.magmutual.com
EOB Analysis
 RemitDATA* www.remitdata.com
 PBIS
http://www.p4healthcare.com/go/Oncology/practicemanage
ment
*-Special relationship with ION
Treasure Trove of Efficiency Tools




Physician E/M Audit
http://www.intelicode.com/
Physician E/M Profiles
http://www.cms.hhs.gov/MedicareFeeforSvc
PartsAB/04_MedicareUtilizationforPartB.asp
#TopOfPage
Protocol Analyzer® www.iononline.com
PQRI Input/ Documentation Forms
http://www.amaassn.org/ama/pub/category/17493.html
In Summary





Do not give up on negotiating with MCOs. Persistence
may pay!
Know your entire situation for each payer where you are
losing money for the protocols you use.
Do not rule anything out in terms of what your practice
may look like in the future…think outside the lines.
Bill for the services that you perform---ALL OF THEM!
Don’t lose $$$ because you did not look hard at your
data aberrancies.
In Summary





Cash is king, queen, jack, and ace. Know what,
why, where, and when about your cash $$$.
Figure out what your real A/R is.
Re-negotiate interest-bearing expenses.
Be careful to only use benchmarks that apply to
your type of facility. But, use data to gauge
performance and performance improvement.
But, do use benchmarks to create physician
and staff incentives.
Keep Paddling!!!!