The financial health of an oncology practice depends heavily on an efficient Revenue Cycle Management (RCM) process. However, oncology billing is uniquely complex due to high-cost treatments, intricate coding requirements, and frequent insurance denials. Without a streamlined RCM system, practices face revenue leaks, compliance risks, and administrative burdens.
At OneHive Business Solutions, we specialize in oncology revenue cycle management, helping practices overcome billing challenges and maximize reimbursements. In this blog, we’ll explore the top billing hurdles in oncology and how our tailored RCM solutions address them.
Why Oncology Billing is More Complex Than Other Specialties
Oncology practices deal with:
- High-cost treatments (chemotherapy, immunotherapy, radiation)
- Frequent coding updates (CPT, ICD-10, HCPCS)
- Prior authorization requirements
- Complex drug billing (buy-and-bill vs. white bagging)
- Frequent claim denials and underpayments
Oncology billing is unlike other medical specialties due to the specialized treatments and high-cost therapies involved. Some of the common complexities include:
- Frequent Treatment Changes: Cancer treatment plans often evolve, leading to billing adjustments.
- Multiple Payers: Managing coordination between insurance companies, Medicare, and Medicaid.
- Prior Authorizations: Many oncology drugs and treatments require pre-approval from payers.
- Compliance Risks: Oncology billing requires strict adherence to regulations, particularly with Medicare and Medicaid.
Without proper expertise, these factors lead to revenue loss, compliance risks, and operational inefficiencies.
Top 6 Oncology Billing Challenges & How OneHive’s RCM Solves Them
1. Frequent Coding Errors Leading to Claim Denials
Challenge:
- Oncology billing requires precise CPT, ICD-10, and HCPCS codes for drugs, infusions, and lab tests.
- A single coding mistake can trigger denials or underpayments.
OneHive’s Solution:
- Certified oncology coders ensure accurate coding for:
- Chemotherapy administration (96401-96549)
- Immunotherapy (J codes)
- Radiation therapy (77261-77499)
- Regular audits to prevent coding errors before claims are submitted.
2. Prior Authorization Delays & Denials
Challenge:
- Many oncology treatments require prior authorization (PA).
- Delays in approvals lead to treatment delays and lost revenue.
OneHive’s Solution:
- Dedicated PA team that:
- Tracks authorization requirements per insurer
- Submissions PAs in advance to prevent delays
- Appeals denied authorizations quickly
3. Drug Billing Complexities (Buy-and-Bill vs. White Bagging)
Challenge:
- Buy-and-bill (practices purchase and administer drugs) vs. white bagging (specialty pharmacies supply drugs) have different billing rules.
- Mismanagement leads to reimbursement losses.
OneHive’s Solution:
- Specialized drug billing expertise to ensure:
- Correct billing for J-codes, NDC numbers, and wastage
- Compliance with payer-specific rules
- Accurate 340B program billing (if applicable)
4. High Denial Rates for Oncology Claims
Challenge:
- 30-40% of oncology claims are initially denied due to:
- Missing documentation
- Incorrect coding
- Lack of medical necessity proof
OneHive’s Solution:
- AI-powered denial prevention that:
- Scans claims for errors before submission
- Tracks denial trends and implements fixes
- Appeals denials with a 95%+ success rate
5. Underpayments from Payers
Challenge:
- Insurers often underpaid due to:
- Incorrect fee schedules
- Bundled payments
- Contractual mismatches
OneHive’s Solution:
- Contractual reimbursement analysis to ensure:
- Payments match negotiated rates
- Underpayments are identified and appealed
- Regular fee schedule reviews
6. Compliance Risks (Audits, Fraud, & Abuse)
Challenge:
- Oncology is a high-risk specialty for audits (OIG, Medicare, private payers).
- Billing errors can lead to fraud allegations and penalties.
OneHive’s Solution:
- Compliance-first RCM with:
- Regular internal audits
- Staff training on latest CMS & payer rules
- Documentation integrity checks
How OneHive’s Oncology-Specific RCM Boosts Revenue
Our end-to-end RCM services include:
✅ Pre-claim scrubbing (reduce denials before submission)
✅ Prior authorization management (prevent treatment delays)
✅ Denial recovery & appeals (maximize reimbursements)
✅ 340B program optimization (for eligible hospitals)
✅ Analytics & reporting (track KPIs like denial rate, A/R days)
Result: Faster reimbursements, higher revenue, and fewer administrative headaches.
Let OneHive Optimize Your Oncology RCM
Navigating the complex world of oncology billing doesn’t have to be a burden. OneHive’s expert RCM services help oncology practices overcome their most pressing challenges, ensuring timely reimbursements and improved financial health.
Partner with OneHive to experience seamless revenue cycle management and focus on what matters most – delivering exceptional patient care.
Oncology billing doesn’t have to be a revenue drain. With OneHive’s specialized RCM services, your practice can:
✔ Reduce denials & underpayments
✔ Speed up collections
✔ Ensure compliance
✔ Focus on patient care, not billing headaches
Ready to transform your oncology revenue cycle – Connect With Us Now!