Oncology Billing: How to Justify Medical Necessity
Oncology is one of those medical specialties that have high regulatory burden. Payers report that diagnostic tests and medications for various cancers are over-utilized. Regulators too are always on the lookout for cases of billing fraud. And because of this added scrutiny, honest providers also struggle with justifying medical necessity on oncology billing claims.
Establishing medical necessity requires a collaborative approach. It requires experienced oncology billing staff and guidance by oncologists in reviewing documentation comprehensiveness. After codes have been assigned medical necessity review should be done by both clinicians and billing supervisors.
Additionally, providers can maintain templates of similar cases for future reference. But to explain it in short, there are two main aspects to justifying medical necessity. They are documentation and review.
Ensure Detailed Documentation in Oncology Billing Operations
After an oncologist has prepared a treatment plan, the oncology billing staff must collate all necessary documents. These documents should provide information about the patient’s medical history, symptoms, and diagnosis. Documents should also contain information about the treatment plan, and other relevant details.
In some cases, providers have to submit diagnostic test reports and consultation notes also. Although there are no specific documents to justify medical necessity, providers must submit all necessary information specific to each case.
Here are some of the most important details that should be supported by documentation:
Symptoms
Medical history
Diagnosis reports & assessment
Treatment plan
Explanation for course of action
To provide all these details accurately and comprehensively providers can either do it themselves or outsource this function to oncology billing services.
Review Billing Codes and Medical Necessity Documents
After all the documents have been organized and relevant ICD-10 and CPT codes have been assigned, providers must review them for accuracy and completeness. This review should be done by both clinicians and oncology billing professionals.
To help avoid errors during this process, providers must use templates and standardized documentation formats. This will help check for missing information that may result in rejection due to lack of medical necessity, especially for over-utilized medical services.
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Burdened by Admin Tasks? Pass it on to Oncology Billing Services
The burden of oncology billing requirements is particularly greater for private physician practices and small to medium-sized providers. Due to their scale of operations, hiring specialists for every function becomes difficult. And so, practices try to get more done with the little that they have.
However, these problems and challenges can be easily avoided with oncology billing services and their expertise in working with both providers and payers. Their streamlined workflows and experienced billing support can ensure cost and accuracy optimization from day one.
To learn more about how our oncology billing services can support your practice management requirements, please contact Sunknowledge Services Inc., a HIPAA-compliant revenue cycle management organization serving US providers and payers since 2007.