Essential KPIs for Better Medical Billing for Oncology 

Medical billing for oncology involves a complex workflow. Especially when an oncologist is dealing with drug billing (Buy-and-Bill), drug wastage (JW/JZ Modifiers), chemotherapy administration codes, and even cases of medical necessity. The NCCN (National Comprehensive Cancer Network) guidelines, payer policies, and clinical trial billing can be equally confusing. This often leads to errors in the reimbursement process.

Furthermore, it is widely recognized that oncology billing is more prone to errors than general medical billing. This is mostly because of high-cost medications, different medical procedures, and strict payer regulations. Thus, caring for patients with cancer requires expertise in handling the billing process. It is also important for every oncologist to follow certain key performance indicators (KPIs) for an efficient oncology medical billing services.

KPIs that matter most in medical billing for oncology:

The treatment of cancer requires precision in handling the entire process, from patient diagnosis to follow-up care. Each and every medical service, medication, and imaging must be billed correctly to ensure proper reimbursement. However, it is quite difficult to keep track of all the service and claim submission. For this reason, following the below KPIs often helps improve the accuracy of medical billing for oncology. It is also important to note that outsourced oncology billing companies monitor these KPIs continuously.

1) Clean claim submission rate

Oncology billing does not only include submitting insurance claims to payers. In most cases, submitting a claim alone does not guarantee reimbursement. The documentation quality and coding accuracy determine whether a claim is accepted. A significant billing challenge is the delay between providing treatment and submitting claims for reimbursement.

Clean claim submission rate measures the percentage of claims submitted to payers that are accepted on the first submission without errors or denials above 95%. A clean claim rate helps oncologists identify and rectify issues like documentation inaccuracies and charge capture errors. The longer it takes to submit claims, the greater the chances of negative impacts on cash flow. Measuring the clean claim submission rate helps oncology practitioners detect errors in claim submission and reduce the time between service delivery and claim submission.

2) Denial rate

As a healthcare provider, it is essential for you to keep track of denied claims. Denial rate is one of the most important KPIs in oncology billing. It measures the percentage of submitted claims that are denied by insurance companies. Also, immunotherapy claims face higher denial rates because payer policies change frequently. With a proper understanding of the reasons behind denials, you can identify and rectify the specific areas of billing.

3) First-pass resolution rate (FPRR)

This KPI measures the percentage of claims that are accepted and processed on the first submission, without any rectifications or resubmissions. A high FPRR indicates a streamlined and effective billing process with fewer claim denials. A low FPRR indicates that there are errors in the billing process that need to be corrected, such as incomplete documentation or incorrect coding. With the help of expert oncology billing services, you can maintain a high FPRR rate in your practice.

4) Days in charge entry

It measures the average time taken for charges to be entered into the billing system after a patient receives services. Timely charge entry is essential in oncology treatments because it involves high-cost medications, infusion therapies, and complex coding. In some cases, the time taken to cover these charges exceeds the treatment time. This creates a gap between the completion of service and claim submission. The outsourced oncology  companies reduce this gap with the implementation of accurate coding, conducting staff training, and using advanced technology to prepare claims.

5) Success rate of prior authorization

Medical billing for oncology depends heavily on prior authorization. Most infusions, imaging tests, and new therapies require approval from insurance companies. It is a concern for oncologists if they are experiencing frequent prior authorization denials in their practice. Successful authorization management directly affects patient care, revenue, and claim acceptance. This is because oncology care involves expensive chemotherapy, immunotherapy, targeted therapies, and advanced imaging.

Since oncology has several complexities, the prior authorization process may require an extensive amount of time to obtain all necessary approvals from payers. The time to authorization refers to the elapsed time between  the  submission of a prior authorization request and the receipt of payer approval. The time taken for PA is usually  measured in hours or days.

6) Coding accuracy

The coding accuracy rate is a critical KPI in oncology billing that measures how correctly medical services, diagnoses, procedures, and medications are translated into standardized billing codes. Oncology practices must measure coding accuracy specifically for infusion and radiation services. The use of correct modifiers is also crucial in medical billing for oncology. Some of the coding metrics in oncology include:

• Overall coding accuracy rate: Measures the percentage of accurately coded claims
• Drug coding accuracy: Measures the accuracy of coding for chemotherapy and specialty medications
• Infusion coding accuracy: Measures correct administration and time-based coding
• Diagnosis coding accuracy: Verifies that cancer diagnoses justify the billed procedures and treatments
• Modifier accuracy: Identifies incorrect or missing modifiers

Many third-party billing companies have certified coders that make your job of accurate coding easier.

7) Accounts Receivable (AR) Days

This oncology billing KPI tracks the average collection period, measuring the number of days between service delivery, claim submission, and payment receipt. Payers take a long time to process claims for expensive oncology services. It is recommended to keep the oncology accounts receivable under 40 days minimum. With effective accounts receivable management, you can maintain claim accuracy, streamline chemotherapy administration billing, and stay updated on all the accounts receivable. If accounts receivable are over 90 days, it represents an aging revenue risk. With the support of effective AR monitoring, oncology practitioners can reduce payment delays, improve cash flow, and strengthen the overall revenue cycle performance.

8) Net collection rate:

This KPI measures the efficiency with which a healthcare provider collects revenue after accounting for contractual adjustments, payer allowances, and unavoidable reductions. Any kind of underpayment can have a significant impact on the oncology revenue generation. The net collection rate helps you determine whether your practice is actually being reimbursed for the services you are providing. It also helps identify underpayments that are often overlooked by the in-house billing teams. If you are successfully collecting the revenue to which you are entitled, it means that you already have a high net collection rate.

Frequent roadblocks that disrupt oncology revenue generation

1) Complex prior authorization

The high cost and complexity of cancer treatments often necessitate payer pre-approvals, with varying insurance policies creating additional challenges in the authorization process. Outsourced billing companies dedicate substantial time and resources to coordinate with payers, facilitate timely treatment approval, and prevent delays in patient care. The urgency of oncology care makes timely authorization critical. This is mostly because delays in the approval process may postpone chemotherapy or radiation therapy initiation. Patients undergoing multi-cycle therapies may require repeated authorization renewals, increasing administrative workload for providers and billing teams.

2) Incorrect coordination of benefits (COB)

These denials occur when discrepancies or unclear payer responsibility make it difficult to determine which insurance plan should process a claim first. This issue is particularly prevalent in oncology, where patients frequently have complex insurance coverage arrangements. Insurance coverage for patients may involve multiple payers, such as Medicare paired with supplemental insurance, employer-sponsored coverage with disability benefits, or private insurance coordinated with Medicaid. Establishing the correct order of primary and secondary insurers is essential to ensure appropriate claim processing and reimbursement for costly oncology services.

3) Bundling of procedures

Bundling denials occur when payers determine that separately billed services are included in a bundled payment, leading to potential revenue loss and administrative follow-up. There is also NCCI (National Correct Coding Initiative) bundling edits that prevent certain CPT/HCPCS codes from being billed separately when one service is considered part of another. Such denials can disrupt reimbursement for a range of oncology services, including supportive care interventions, and imaging performed throughout the course of treatment. With the introduction of new cancer therapies and billing codes, maintaining accurate and complete claims becomes increasingly challenging. The billing teams must continually adapt to evolving bundled coding requirements and ensure proper application of coding guidelines.

In most cases, these challenges in medical billing for oncology lead to documentation errors and coding discrepancies. Oncologists struggle to get proper reimbursement because the claims are denied by payers due to billing errors. As a result, many oncology practices choose to outsource their billing operations.

Why choose SunKnowledge for oncology billing?

As a healthcare provider, you must have come across multiple challenges in your way towards patient care and revenue generation. You must also agree that handling these challenges is never easy. At SunKnowledge, we offer best-in-class services to enhance your entire oncology revenue cycle management process. With over 17 years of experience, we offer tailored billing solutions that include a wide range of benefits. Our highlights include a first-pass collection rate of 97%, all-inclusive pricing and real-time services across all U.S. time zones.

When it comes to getting reimbursement for every single penny, we do not leave any stone unturned. Our excellent client references provide a clear insight into the quality of services. With just one call, you can get professional help in reducing billing challenges and effectively follow KPIs in your medical billing for oncology. As our expert team of oncology billing services continuously monitor billing KPIs, identify revenue leakage, improve coding accuracy, and help practices strengthen reimbursement performance.