Unauthorized Fractions:  To Bill or Not to Bill?

We’ve been writing extensively on the growing trends in prior authorizations in radiation therapy and more recently we’ve been presented with the question of how to bill for unauthorized fractions.  It is becoming more common for managed care plans to contest the fractionation schedules ordered by the radiation oncologist.  These payers, or their utilization management companies, may authorize only a certain number of fractions for certain diagnosis and treatment courses.  If your providers disagree with the authorized treatment plan and intend to treat the patient with unauthorized fractions, your business office or radiation oncology billing service will need to address the question of how to handle the unauthorized fractions.  Do you bill for them even though they’re not authorized, or do you only bill for those that have been approved?

We recommend billing for all services provided regardless of the prior authorization limitations, but with the following caveats:

• Separate the claims into the approved services and unapproved services. Some payers may deny only the unapproved charges on a claim, but some may deny the entire claim if it’s not a “clean” claim.  To avoid problems billing for the approved services, we suggest submitting the treatment planning, simulation, and approved fractionations under an initial claim that the payer has approved.  Make sure to include the prior authorization number with the claim.  To ensure that your claims match your medical documentation of the course of treatment, then submit additional claims for the unapproved fractions.  Chances are that these claims will be denied, but at least you minimize the risk of holding up payment on the entire course of treatment due to submitting both approved and unapproved procedures in the same claim.  In addition to maintaining the possibility of reimbursement, billing for these services preserves compliance and the integrity of the practice management data.
• Plan to Appeal. Just because all fractions were not approved in the prior authorization process does not mean that an appeal will be unsuccessful.  If you can make an appeal with valid claims that the delivered course of treatment complied with either ASTRO or NCCN guidelines, an appeal may be successful.  Be prepared to submit additional clinical information to support the appeal and ensure that the payers appeal process is followed by a knowledgeable appeals specialist.

The other alternative of only billing for the authorized fractions may be “easier” initially, but may lead to numerous issues with compliance, practice data integrity, and missed opportunities.  Modern practices are becoming more sophisticated with using revenue cycle data for various practice management decisions.  Often the analytics are based off the billing codes so any discrepancy between delivered services and billed services creates misleading analyses, and with prior authorization requirements projected to continue increasing, we think the approach recommended above will only grow more important.