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Practice Management Billing Tools for Radiation Oncology

White papers·

This white paper has three objectives:

  • To discuss practice management billing tools
  • To review system workflow options
  • To show why a practice needs an action plan to get maximum reimbursement

Real-time eligibility

Real-time eligibility is the online verification of a patient’s insurance eligibility and policy demographic data. Used properly, it greatly reduces denials caused by bad policy information.

The workflow is simple. The billing system sends patient inquiry data to the payer. The payer responds through the billing system and states whether the patient’s policy is active or inactive.

The main benefit is accuracy:

  • Policy data returned by the payer is the most accurate data available, because it is the data the payer expects to see on the claim.
  • When possible, create the patient’s billing data directly from the payer’s response.

Inquiries can be made on new patients, and they can also be used to verify that the data on file for existing patients is still valid.

Systems integration with Record and Verify and the EMR

Radiation oncology is unusual because it has three systems that can be integrated:

  • Record and Verify
  • EMR/EHR
  • Billing system

Importing data between these systems with HL7 interfaces has four benefits:

  • Increased staff productivity
  • Fewer missed charges
  • Improved data accuracy
  • Consistency

Integration options

Practices can connect the three systems in several ways:

Configuration How data flows Notes
Without an EMR/EHR The Record and Verify system sends demographic and/or charge data directly to the billing system. Especially useful when the practice has no EMR.
Record and Verify and EMR, one direction Data passes in one direction between the Record and Verify system, the EMR and the billing system. Reflects the most natural workflow.
Record and Verify and EMR, with updates back to the EMR Data flows into the billing system, and the billing system also sends data back to the EMR. In this case, the billing system updates the EMR.
Fully integrated All three systems exchange data with each other. A fully integrated solution.

These options are only a few of the possible system integration configurations. Each practice should consider its own workflow and its costs when it decides how to integrate separate systems.

Claim scrubbers

A claim scrubber checks your charges before claims are created. A good scrubber can include several kinds of rules:

  • CCI edit rules. The scrubber alerts you to violations of the CCI (Correct Coding Initiative) edit rules defined by CMS. For example, it flags an attempt to bill an office visit, such as 99205, and a simulation, such as 77290, on the same day.
  • Conflict rules. The scrubber alerts you to potential billing problems caused by conflicting billing data. An example is an attempt to bill a CPT code with an incorrect place of service.
  • Replacement rules. The scrubber may suggest that you replace one CPT code with a different one. For example, it may suggest replacing 99245 with 99205, because 99245 is no longer accepted.
  • Custom splitting rules. An example is the need to split treatment devices (77334) between two service lines and add modifier 76 to the second line.
  • Payer-specific rules. These include Local Coverage Determinations (LCDs) and custom rules that run only for specific payers.
  • Authorization rules. Available with certain billing systems, these alert you when a patient’s policy requires prior authorization but no authorization is on file.
  • Auto-creation of new charges. The scrubber reminds you to bill certain charges. For example, it reminds you to bill the 77427 weekly treatment management charge after 5 treatments, or at the end of a treatment course when 3 or more treatments remain.

Claim scrubber workflow

How the scrubber fits into your workflow matters as much as its rules.

A fully integrated scrubber is the best solution. It takes two steps:

  1. The system scrubs charges automatically as they are captured, or the user selects the scrub function during charge capture.
  2. The biller reviews the suggested changes and makes revisions directly in the billing system before claims are generated.

An external scrubber takes five steps:

  1. The user exports charge data to the external system to be scrubbed.
  2. Billing staff wait for the external system to report that the charges have been reviewed and scrubbed.
  3. The biller retrieves the replies from the external scrubber.
  4. The biller reviews the suggested changes or problems in the external scrubber.
  5. The biller finds the matching data in the billing system and makes the required changes.

Electronic claims processing

Different practice management systems use different workflows for electronic claims. Each method has advantages and disadvantages.

External system

In this workflow, staff manually export claims from the billing system to an external system, which sends them to the clearinghouse. Payer responses return the same way, and staff must manually import them into the billing system.

  • The external method is more labor-intensive than the other methods.
  • It requires more steps.
  • It takes longer for staff to learn.
  • It may cost less in cash outlay.

Internal system with segmented processing

In this workflow, the billing system sends some claims through a clearinghouse and sends others separately to individual payers (Payer A, Payer B and Payer C).

  • It may be more cost effective than using a single clearinghouse for all payers.
  • It could be much more costly in staff productivity.
  • Staff must learn several methods for sending claims and receiving responses, which can lead to mistakes.

Internal system with fully integrated processing

In this workflow, the billing system sends claim data for all payers through a single clearinghouse, and all payer responses come back through the same clearinghouse into the billing system.

  • It is simple and easy to use.
  • It is the most efficient method, but it could make the system more costly.
  • There is no need for separate steps to transmit claims.
  • Staff do not have to print reports to receive and act on payer responses.

Electronic remittance advices

Different practice management systems also use different workflows for electronic remittance advices (ERAs). The differences come from system capabilities and how each system is structured. Consider how well your practice’s workflow fits the billing system’s workflow. Practice management systems that receive ERAs automatically increase efficiency.

The same three configurations apply to ERAs:

  • External ERA processing. The clearinghouse exports ERAs to an external system, and staff must manually import them into the billing system. As with claims, this method is more labor-intensive, requires more steps and takes longer to learn, but it may cost less in cash outlay.
  • Multiple ERA processing. ERAs arrive from a clearinghouse and separately from individual payers. The practice management system may or may not be connected directly to the clearinghouse and the payers. If it is not connected, ERAs arrive at an external system and must be imported manually.
  • Fully integrated electronic system. Claim data goes out, and ERAs come back, for all payers through a single clearinghouse.

Integrated ERAs and auto-adjudication

If the system can auto-adjudicate ERAs, it reduces the payment posting workload. This in turn shortens the time between payment from the primary payer and generation of the claim to the next payer.

When you evaluate a system, keep two other points in mind:

  • Systems give different levels of oversight over auto-adjudication.
  • It is very helpful if the billing system can produce a human-readable ERA.

Building a billing action plan

Having the necessary tools is critical. Without an action plan, however, you cannot master the billing cycle.

  1. Examine the entire billing cycle and all of its required steps. Think about your practice management system’s workflow and how it fits with the workflow in your office.
  2. Divide the billing cycle into categories. Examples include:
    • Creation of the patient billing chart, which could include real-time eligibility
    • Charge capture, which could include both manual charge entry and data imports from outside systems
    • Claim scrubbing, which may be fully integrated and therefore not a separate task
    • Claims generation, paper and electronic
    • Claims submission
    • Patient statements, including creation and mailing
  3. Divide each category further into measurable steps. Include every part of the billing cycle, including the use of practice analytics.
  4. Assess each staff member’s role in the practice. Assign billing tasks based on each person’s role and individual strengths and weaknesses.
  5. Assign specific billing tasks to individuals and hold them accountable. Set measurable timeframes for performing and completing each task.

Sample billing task chart

A task chart lists each billing task, the days it is done and the staff member responsible. Each task has a specific staff member assigned, and you can set the days of the week each task is carried out. This sample shows the tasks and schedule; the staff column is left for the practice to fill in.

Scheduled tasks

Task Schedule
Batch insurer claims and mail paper claims Tuesday and Thursday
Work claims in warning status in the Batch Insurer screen Tuesday and Thursday
Batch, review and mail patient invoices Monday
Monitor electronic claim batches in the Electronic Claims Queue Daily, Monday to Friday
Clean-up audit Wednesday
Import charge data from Record and Verify software Tuesday
End-of-treatment (XRT) chart checks (move patients to completed in Iridium Suite) Friday
Work insurer A/R Daily, Monday to Friday
Follow up on denials and insurer correspondence Daily, Monday to Friday
Post payments and denials Daily, Monday to Friday
Monitor ERAs Daily, Monday to Friday
Review and work patient aging Wednesday
Review questions on current patients under management or treatment Thursday
Refunds Once a month

Ongoing tasks: suggested front office duties

  • Obtain a short registration from the patient to run real-time eligibility.
  • Create the patient chart from the real-time response, then open the demographics to add missing information (Social Security number and phone number).
  • Scan a copy of the patient’s insurance cards and driver’s license into the documentation tab in Iridium Suite.
  • Collect copays or payments from patients and post them to the patient account.
  • Obtain treatment authorization and log the result in Iridium Suite with the patient’s insurer.

Other tasks

Task Schedule
Configure status settings: A/R statuses, account adjustment types and similar settings As needed

Finally, use your biller efficiency reports to hold your staff accountable for their productivity.

What has changed since this was written

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