Oncology billing and accounts receivable

Medical oncology bills a treatment plan, not a visit: infusions, sequential and concurrent administrations, hydration, injections, and the drug itself, which the practice buys up front and is reimbursed for only once the claim clears. The money sits in the drug, so one unit conversion error or one lapsed authorization can cost more than a full day of office visits.

Where the money leaks in oncology

These are the recurring denial reasons in this specialty. They are not exotic. They are the ordinary ones that go unworked because the person who could fix them is at the front desk answering a phone.

• Infusion start and stop times missing from the nursing record, so the initial, sequential and concurrent hierarchy cannot be supported and the extra administrations fall off the claim.
• Drug quantity billed in milligrams instead of the billing units set out in the code descriptor, or worked out from a weight never recorded on the day of treatment.
• Discarded remainder of a single-dose vial not documented in the chart and never billed as wastage, so the practice absorbs the unused portion of an expensive drug.
• Regimen changed at progression but treatment continued under the old approval, so every cycle of the new drug denies as not authorized.
• Payer required the drug through its contracted specialty pharmacy, the practice infused from its own stock, and the buy-and-bill claim was denied in full.
• Off-label use with nothing in the note tying the drug to compendium or literature support, so it denies as not medically necessary and the appeal has no chart behind it.

What a seat does about it

One trained person works your queue from the difficult end. Every call is logged with the payer reference number and the outcome, so an appeal can quote what was said rather than start again. Denials are categorised, which is how the same reason stops coming back next month. On Friday you get it in writing.

The roles that matter most in this specialty are AR calling and denials at $1,700, prior authorization at $1,900, and certified coding at $2,500.

The codes those turn into

Each of these is a denial code you are likely to meet working oncology, matched to the problem above it in your own words. The route back to payment differs by code, so a queue sorted by recovery route clears faster than one sorted by date.

• CO-252 — Additional documentation required
  The payer will not decide until it sees paperwork. Nothing happens until it arrives.
  Recovered by being answered with the document the payer names. Matched from: “Infusion start and stop times missing from the nursing record, so the initial, sequential and concurrent hierarchy cannot be supported and the extra administrations fall off the claim.”
• CO-16 — Claim lacks information
  Something on the claim is missing or malformed. On its own the code tells you nothing — the detail is in the remark code that comes with it.
  Recovered by being corrected and resubmitted. Matched from: “Drug quantity billed in milligrams instead of the billing units set out in the code descriptor, or worked out from a weight never recorded on the day of treatment.”
• CO-50 — Not deemed medically necessary
  The payer does not accept that the documentation supports the service. This is a clinical argument, not a clerical one.
  Recovered by being appealed with clinical documentation. Matched from: “Discarded remainder of a single-dose vial not documented in the chart and never billed as wastage, so the practice absorbs the unused portion of an expensive drug.”
• CO-197 — Prior authorization absent
  The payer required prior authorization for this service and cannot find one attached to the claim.
  Recovered by being taken back to the authorization. Matched from: “Regimen changed at progression but treatment continued under the old approval, so every cycle of the new drug denies as not authorized.”
• CO-45 — Charge exceeds the fee schedule
  A contractual write-off rather than a denial. It only becomes a problem when the allowed amount is wrong.
  Recovered by being checked against the contract before any work is done. Matched from: “Payer required the drug through its contracted specialty pharmacy, the practice infused from its own stock, and the buy-and-bill claim was denied in full.”
• CO-151 — Too many services billed
  The payer accepts the service but not the quantity or the frequency at which it was billed.
  Recovered by being appealed with clinical documentation. Matched from: “Off-label use with nothing in the note tying the drug to compendium or literature support, so it denies as not medically necessary and the appeal has no chart behind it.”

Working a denied claim costs $57.23 per denied claim in administrative time (source), and about about 90% of initially denied claims are eventually paid. Most of what sits in a oncology AR bucket is not lost money. It is money waiting for somebody with the hours to make the call.

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