FINDING YOUR HAPPY PLACE RITA GENOVESE, CPC,PCS APRIL 2016 The Magical World of Oncology Billing…
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FINDING YOUR HAPPY PLACE
RITA GENOVESE, CPC,PCSAPRIL 2016
The Magical World of Oncology Billing…
Agenda
Common Denials
Hydration Issues
Process for Newly Approved Drug Therapies
Chemotherapy Authorization Process
Non Par Authorization Process
Reauthorization
Place of Service Issues
Patient Assistance Programs: Drug Replacement
Financial Counseling
Common Denials
Eligibility Denials
Authorization and Coding Denials
Diagnosis Coding
Authorization Denials
Non Covered Services Denials
Coordination of Benefits
Coding
Duplicate Claim
Untimely Filing
Hydration Issues
Each outpatient encounter must be supported by a physician order that is complete with a definitive diagnosis, sign, or symptom. If indicated, an Advance Beneficiary Notice (ABN) of Non-Coverage may also be required for billing. Determining whether to issue an ABN is based on the drug to be administered.
Order needs to provide sign or symptom that supports medical necessity for pre-/post-medications or hydration
Physician plan of care must correlate with patient’s signs and symptoms rather than drug specific protocol
“PRN” or “as needed” orders for antihistamines, antiemetic, or hydration is not sufficient – must include signs/symptoms to support medical necessity
Hydration administration must support medical necessity versus standard of care or facility protocol
Hydration
Codes 96360-96361
Used to report a hydration IV infusion to consist of pre-packaged fluid and electrolytes (e.g., normal saline, D5W), but not drugs or other substances
Do not report if infusion time 30 minutes or less
Report add-on code 96361 for hydration intervals of > 30 minutes beyond 1 hour increments
Report 96361 if hydration provided as secondary or subsequent service after a different initial service administered through same IV access. Can also be performed prior to another infusion
Do not report if performed concurrently with other infusion services or to “keep open” line between infusions or when free-flowing during chemo or tx/pro/dx infusions
Hydration Examples
IV infusion of normal saline: start 13:25/end 13:45
Do not report
IV infusion of normal saline: start 13:25/end ?
Do not report
IV infusion of D5W/Infusion: start 13:25/end 14:45
Report 96360 only
IV infusion of D5W/Infusion: start 13:25/end 14:56
Report 96360 and 96361 x 1
What Can Be Reported Separately
Hydration, if administered as a secondary or
subsequent service associated with chemo IV
infusion through the same IV access, if time
requirements met for reporting hydration
What Not to Report Separately
Fluid used to administer the drug is
incidental hydration
DRUG THERAPIES
Process for Newly Approved
New drug therapy is identified by physician.
Physicians are required to submit New Drug Review Request to centralized committee.
The request is forwarded to lead pharmacist and revenue cycle.
All requests will be brought to New Drugs Committee.
All information will be collected and presented for discussion:
Drug acquisition costs
Reimbursement policies per carrier
Medical information
Safety issues
FDA mandated REMS programs for prescribing and dispensing
Committee will review and discuss
A recommendation will be created by the committee and presented
Once the recommendation has been approved, Nursing will be educated on infusion guidelines
Revenue Cycle will monitor payment per carrier and present statistics to administration
Pharmacy orders the medication
CDM is created if administered on hospital/ facility side
Generic CPT code used for physician offices
Chemotherapy Authorization Process
Acquire chemo authorizations in a timely manner; begin in 24 hours/complete in 72- hour goal, or peer-to-peer
Daily review of incoming authorizations
Timely communication to the care team
Access to clinical staff for peer-to-peer review
STAT cases
What is a STAT case?
Documentation required for a STAT case
Complete and accurate information on the authorization request
Intake form from care team
Standard Process
Care team completes chemo review request electronically
Billing office prepares authorization
Billing office enters information on electronic request form
Billing office documents authorization information in the EMR
Completed, approved review forms go to infusion schedulers electronically
Infusion schedulers review with infusion charge nurse for appropriate appointment date/time
Infusion scheduler contacts care team and patient to schedule appointment
Denial Process
Insurance company denies initial chemo request
Care team is notified
Physician may conduct peer-to-peer review
Alteration in treatment plan possible
Formal appeal letter may be required
Response letter sent to physician’s office
Nurse notifies Billing office of response
If denied, patient options are discussed (e.g. Charity Care, additional appeals, coverage change, etc.)
Non Par Authorization Process
Contact provider service authorization department
Have provider service rep double check provider information using NPI and tax ID
Request an out of network authorization based on continuity of care
Complete the form and attach clinical documentation
If the insurance company does not have a form, fax the clinical information with a cover letter
When non par authorization is received, add information to non par spreadsheet
Using the non par spreadsheet, check each patient’s schedule once a week to determine when another authorization is required
Reauthorization
Changes in the patient’s weight, treatment frequency or dosing during the patient’s regimen date span may require approval by the payor.
Reauthorization staff reviews the scheduled patients’ clinical information on daily basis. If there is a change in the weight, dose and/or frequency of treatment, the clinical team is advised to initiate a new chemotherapy review.
A new authorization is requested with updated clinical information is call into the patient’s insurance company.
Once the new authorization is received, the chemo review is approved and the clinical team is advised.
Place of Service Issues
Some payors require injectable chemotherapy drugs be administered in the specialist’s office. Listed are some examples that may require authorizations:
interferon leuprolide
filgrastim pegfilgratim
plerixafor nplate
denosumab infliximab
sandostatin xgeva
Complete insurance verification of patient’s benefits. During verification process, a check should be done to see if any injections must be done in the specialist’s office.
If an authorization for the injection(s) is needed, the clinical team is made aware and the authorization request is initiated.
This request can be made by form or phone, depending upon the payor’s requirements.
Once the authorization is approved by the payor, the request is approved.
Clinical team is advised via phone, email and/or task.
DRUG REPLACEMENT
Patient Assistance Programs
P A T I E N T A S S I S T A N C E P R O G R A M S A R E S E T U P B Y D R U G C O M P A N I E S W H I C H O F F E R F R E E O R L O W C O S T D R U G S T O U N I N S U R E D I N D I V I D U A L S W H O C A N N O T A F F O R D T H E I R M E D I C A T I O N . M O S T B R A N D N A M E D R U G S A R E F O U N D I N T H E S E P R O G R A M S .
C O M P A N I E S O F F E R T H E S E P R O G R A M S V O L U N T A R I L Y ; T H E G O V E R N M E N T D O E S N O T R E Q U I R E T H E M T O P R O V I D E F R E E M E D I C I N E .
Who is eligible for these programs?
Each program has it's own rules. Some common requirements are:
Be a U.S. citizen or legal resident
Have no prescription insurance coverage
Meet program income guidelines
Can I apply for assistance if I have insurance or prescription coverage?
Some Patient Assistance Programs will help those who have insurance if they meet program hardship requirements or their medication is not covered by their insurance
Can I apply for these program if I haveMedicare Part D?
It depends on the company. Some companies will let people with Part D apply for their programs. Other companies may review applications on a case-by-case basis.
Helpful Websites www.needymeds.org
www.rxassist.org
Financial Counseling
Uninsured Patients
Complete Financial Assessment
County/Medicaid
If eligible apply for state Medicaid program
Healty Horizon
MAWD (Medical Assistance for Workers with Disabilities)
BCCPT (Breast and Cervical Cancer Prevention Treatment)
Adult Category
If ineligible, discuss ACA (Affordable Care Act) Insurance options
Underinsured Patients
Complete Financial Assessment
County/Medicaid Application
If eligible for state Medicaid program
Health Horizon
MAWD (Medical Assistance for Workers with Disabilities)
BCCPT (Breast and Cervical Cancer Prevention Treatment)
Adult Category
Specific Drug Copay Program
Usually no income requirements
Will cover the cost for the specific drug minus a small copay ($25)
Copay Assistance Foundation
Income Requirement (400-500% FPL)
Depending on the program may only cover patient’s responsibility for the chemo drug but not the administration or premedication
Hospital-Based Charity Care Program
QUESTIONS?
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