Oncology and infusion
revenue cycle management.
Oncology and infusion billing carries the highest revenue risk in ambulatory care. High-cost drugs, unforgiving unit math, and payers that deny first and ask questions later. It is our leading specialty, not a side line.
J-code mapping and NDC unit alignment
The conversion between the NDC unit a drug is purchased in and the HCPCS unit it is billed in is where infusion billing usually leaks. A vial size that does not divide cleanly into the billing unit produces a claim that is wrong in a way nobody notices until the remittance arrives.
- NDC-to-HCPCS unit conversion checked before submission
- Administered units reconciled against billed units on a claim sample during the assessment
- MUE limits checked against high-dose regimens before the claim goes out
JW and JZ modifiers, applied consistently
Single-dose vials produce discarded drug, and the modifier that reports it is not optional. JW reports the wastage, JZ attests that there was none. Applying one where the other belongs is a denial, and applying neither is a denial that arrives later.
- JW and JZ applied to drug wastage, correctly and consistently
- Buy-and-bill workflow management to prevent drug-billing leaks
Chemotherapy and complex infusion pre-authorization
An authorization that does not match the treatment date is the same as no authorization. Regimens change between the request and the chair, and the payer holds you to what was approved, not to what was given.
- Real-time chemotherapy and complex infusion pre-authorizations
- Prior authorization tracked to the treatment date
- Escalated to peer-to-peer review when a payer refuses
High-value denials appealed, not written off
A denied oncology claim is worth many times a denied office visit, so the arithmetic of chasing it is different. Denials are sorted by CARC and RARC code rather than by dollar value, because the same reason repeating is one workflow problem rather than many separate ones.
- Rapid appeal of high-value oncology claim denials
- Denials grouped by CARC/RARC so the pattern is visible
- Denial reasons ranked by frequency and by dollars, not just a total
This is what we watch for. How the engagement runs is a separate question.
Before any of it applies to your practice we read your aged A/R and the last quarter of remittance advice, and you get the findings in writing including what we think is not worth chasing. You keep your practice management system, your payer contracts and your NPI throughout.