Top 3 Challenges in Community Oncology Revenue Cycle Management

Community oncology continues to experience a dramatic shift in market dynamics. Substantive developments include a proliferation of acquisitions, the CMS Merit-Based Incentive Payment System (MIPS) and larger shift to value-based reimbursement models, as well as exploration of precision medicine as the standard of care.

Notable changes that directly constrain practice financial health include fee schedule changes, temporary COVID-19 care disruptions, heightened competition with hospitals and health systems, a shortage of oncologists, and high medical equipment and maintenance costs.

How are these phenomena impacting revenue cycle management in community oncology?

A 2021 study conducted by The Lynx Group, commissioned by XiFin, identified the top three community oncology RCM (Revenue Cycle Management) challenges not adequately addressed by current resources, processes, and technologies:

Respondents generally agreed that most appeals are eventually resolved successfully. Unfortunately, the cost of appeals under current processes negatively impacts practice finances. For example, one respondent pointed out that the average call wait time is 20-30 minutes and more than one transfer is often necessary just to reach the correct individual at the payor. Another described the appeals process as arduous, time-consuming, and even combative when the payor representative does not have experience in the specialty.

A proven solution for this predicament is afforded by a technology-driven RCM solution designed to enable root cause analysis for repeated problem areas, prevent unnecessary denials, and automate time-consuming aspects of appeals.

BI Tools that Target Critical Areas

Improved analytics, presented via user-friendly dashboards, enable more effective RCM administration. This starts by quickly isolating the most common front-end billing issues and the clients or other reasons that may be triggering them. Next, we examine denials management, holistically and with drill-down capability, to highlight the biggest headaches and optimal solutions.  For example, we look at how many appeals are sent, which payors and procedures require the most appeals, and which corresponding appeals prove successful. Finally, we employ productivity analysis tools (e.g., heat maps) to understand team and individual performance in executing these tasks.

Building these analytical capabilities internally requires substantial investment in BI, database architecture, systems integration, development, QA and related resources. The right RCM solution, purpose-built to address the dynamic requirements of community oncology billing, provides a near-term alternative that avoids these fixed costs.

Front-end Automation Avoids Unnecessary Delays

Increasing the percentage of clean claims entering the workflow directly correlates to more favorable “days in AR,” cash collected, and other critical metrics. Helpful front-end RCM capabilities for avoiding cumbersome denials can include:

• Automated error correction with referring physicians via web services
• Patient data discovery: Integrated within patient and client correspondence workflows; identifies and fixes inaccurate patient data and improves client and patient experiences
• Automated eligibility checks
• Automated authorization checks
• User-friendly client and patient portals with real time connectivity.
• Payor edit automation: Published payor edits are automatically updated to ensure claims meet current payor requirements prior to submission
• Automated consolidation rules with compliance logic and prompts: Simplifies payor billing rules to comply with health care policies and requirements; ensures the appropriate number of service units are billed for a specific date of service based on payor MUEs (Mutually Exclusive Edits); bundled services are billed with the correct procedure code(s) and modified or appended as needed based on NCCI (National Correct Coding Initiative) edits and AMA codes
• Fee schedules based on contracted/negotiated rates (by payor and procedure code), with analytics to show discrepancies in adjudicated allowed amounts
• Configurable outpatient-specific workflow logic to address relevant claims requirements
• Patient responsibility estimator with up-front visibility to real-time patient out-of-pocket liability

Enhancing Denial Management Maximizes Efficiency

Connectivity and automation are key to achieving impactful results in claim denial management. The following functionality provides the substance for these capabilities in a suitable revenue cycle management solution:

• Payor connectivity with real time claim status, for faster notifications and responses
• Automated appeal processes, including override reason codes and prioritized actions
• Denial code management to initiate responses (i.e., correspondence, bill next payor, or appeal)
• Automated attachment of supporting documentation such as medical records and pathology reports
• Ability to access lab-specific appeals functionality (e.g., molecular testing)
• Payor-specific front-end edits, supporting custom payor rules
• Automated bulk appeals
• Support for prepopulated payor-specific letters and forms

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