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?