Ray Page, DO, PhD
When coding and billing consultant Roberta Buell mentions that payers are taking dramatically longer to pay claims, oncology practice administrators nod in agreement. At Carolina Blood and Cancer Care, Kashyap Patel, MD, who attended a recent public address1
by Buell, said that it is now taking up to 3 months to get paid, up from maximum delays of a month a few years ago. And Ray Page, DO, PhD, said that the constant delays and treatment denials he has seen at his Texas-based practice, the Center for Cancer & Blood Disorders, have caused losses, led to physician burnout, and adversely affected patients’ treatment regimens.
Both men say their practices are doing all they can, but it’s still a struggle to stay on top of the revenue cycle. “We noticed such a dramatic change in payment times this year that we thought we needed to bring it up with the physician board,” Page said. “We’re coming around for the next cycle of drugs, and we haven’t gotten paid for the first one. And in some cases, we even get into a third cycle of treatment without being paid for the first. That’s a huge financial outlay that practices can’t afford.”
As increasingly pricey therapies come on the market, payers have grown more cautious about issuing payment approvals. Documentation requirements are stiffer, practices must traverse more gateways during the approvals process, and a lot more explaining must be done to convince a payer that therapy choices made by doctors are medically necessary (Table).
Table. Top Reasons for Payer Payment Denials in 2016
The majority of Medicare Part B drug claims are generally paid within a month, according to Buell, of onPoint Oncology in Hudson, Ohio. Her review of focalPoint 2016 data from 165 cancer centers across the country found that 63% of accounts receivable claims were less than 1 month old; 18.6%, between 1 and 2 months old; 4.51%, up to 3 months old; 2.51%, up to 120 days old; and 11.32%, up to 4 months old.
Some payers were singled out by Buell for taking up to 3 months to pay intravenous drug claims, although she praised others for being especially good about paying these claims. Several payers were asked to comment for this article, including Mutual of Omaha, LaSalle Medical Associates, Nevada Blue Shield, Delaware Blue Cross, and New Mexico Blue Cross. None responded. Buell’s data indicated that each took an average of 2 months or longer to pay claims for injectable drugs.
When it comes to types of service, the payment rates look better: among payers in general, evaluation and management claims required an average of 18 days for payment in 2016; imaging, 37 days; radiation, 28 days; and drugs, 36 days. Practices have responded to the changes in payment policy by beefing up staff dedicated to handling claims and ensuring payment. Page said that his practice has increased its preauthorization staff from 2 to 5 people: “a 150% increase in staffing—folks who do nothing but preauthorization.” Patel said his North Carolina practice recently increased its preauthorization staff as well, from 1 to 2. A few years ago, his practice didn’t employ anyone whose sole job function was securing preauthorizations for treatment.
“One of the employees started on the front desk, and now this is all she does. And we just hired another employee at the other office just to ensure we don’t drop the ball on anything,” Patel said. He said employees need to obtain preauthorization for drugs, especially high-priced ones, because of the possibility that payers will refuse to pay. “My blanket observation is: If the medicine is expensive, they will always give us a hard time, no matter what.”
Page said that hiring multiple people to handle preauthorization isn’t an ideal long-term solution. First, there’s the cost; and, second, securing preauthorization for a treatment doesn’t guarantee that the treatment will be paid for. He dreams of a world where the revenue cycle is fully automated, with physicians using their electronic health record system and evidence-based treatment pathways to show payers why a treatment is necessary, rather than “burning up our fax machines,” then waiting weeks for a response.