Category: Denials Management

More insurance billing information and guides visit axisirg.com.

Here’s a cheat sheet for insurance billing related to substance abuse and mental health:

  1. Verify insurance coverage: Before beginning treatment, it’s important to verify the patient’s insurance coverage for substance abuse and mental health services. This includes checking if the insurance plan covers the specific services being provided, such as individual therapy, group therapy, or medication management.
  2. Obtain pre-authorization: For certain types of treatment, such as inpatient hospitalization or intensive outpatient programs, pre-authorization from the insurance company may be required. Make sure to obtain this authorization before beginning treatment to avoid any billing issues.
  3. Check for co-pays and deductibles: Determine the patient’s co-pay and deductible amounts for substance abuse and mental health services. These amounts may be different from those for general medical services, so it’s important to double-check.
  4. Code accurately: Use the correct billing codes for the services provided. This includes the diagnosis codes for the patient’s mental health or substance abuse condition, as well as the procedural codes for the specific services rendered.
  5. Submit claims promptly: Submit claims to the insurance company promptly after the services are provided. This will help ensure timely payment and prevent any delays or denials.
  6. Follow up on unpaid claims: If a claim is not paid within a reasonable amount of time, follow up with the insurance company to determine the reason for the delay. This may require resubmitting the claim or providing additional documentation.
  7. Document thoroughly: Document all services provided and any communication with the insurance company related to billing or reimbursement. This will help ensure accurate billing and prevent any potential audit issues.

By following these guidelines, you can help ensure accurate and timely insurance billing for substance abuse and mental health services.

CPT Cheatsheet

The most common CPT Codes used by professional clinicians and therapists

Diagnostics:

• 90791 – Psychiatric Diagnostic Evaluation (usually just one/client is covered)

• 90792 – Psychiatric Diagnostic Evaluation with medical services (usually just one day per client is covered)

Therapy:

• 90832 – Psychotherapy, 30 minutes (16-37 minutes).

• 90834 – Psychotherapy, 45 minutes (38-52 minutes).

• 90837 – Psychotherapy, 60 minutes (53 minutes and over).

• 90846 – Family or couples psychotherapy, without patient present.

• 90847 – Family or couples psychotherapy, with patient present.

• 90853 – Group Psychotherapy (not family).

Crisis:

• 90839 – Psychotherapy for crisis, 60 minutes (30-74 minutes).

• +90840 – Add-on code for an additional 30 minutes (75 minutes and over). Used in

conjunction with 90839.

Other:

• +90785 – Interactive Complexity add-on code. Covered below.

There are also E/M (evaluation & management) in conjunction with psychotherapy, used by

authorized prescribers. Coding E/M is trickier, harder to document and more vulnerable to

audit but usually results in greater reimbursement. There’s also a series of E/M codes that are

used without the psychotherapy component. For more in-depth coverage on E/M coding for

psychotherapy there are some good free webinars released by AACAP on E/M CPT Codes.

• +90833 – E/M code for 30 minutes of psychiatry (used with 90832).

• +90836 – E/M code for 45 minutes of psychiatry (used with 90834).

• +90838 – E/M code for 60 minutes of psychotherapy (used with 90837).

For Facilities and Offices/Clinics

Residential Treatment:

  • H0018: Behavioral health; residential, per diem
  • H0019: Substance abuse treatment; per diem

Partial Hospitalization:

  • H0035: Mental health; partial hospitalization, treatment, per diem
  • H0015: Substance abuse treatment; partial hospitalization, per diem

Intensive Outpatient:

  • H0016: Behavioral health; intensive outpatient program, per session
  • H0017: Substance abuse treatment; intensive outpatient program, per session

Outpatient:

  • 90832: Psychotherapy, 30 minutes with patient and/or family member
  • 90834: Psychotherapy, 45 minutes with patient and/or family member
  • 90837: Psychotherapy, 60 minutes with patient and/or family member
  • H0004: Behavioral health; counseling and therapy, per 15 minutes
  • H2035: Substance abuse treatment; group counseling, per 15 minutes
  1. Other Services:
  • 96150: Health and behavior assessment
  • 96151: Health and behavior reassessment
  • 96152: Health and behavior intervention, individual
  • 96153: Health and behavior intervention, group (2 or more patients)
  • 96154: Health and behavior intervention, family (with patient present)

It’s important to verify the correct codes with the insurance company and ensure accurate billing to prevent any potential issues with reimbursement.

These codes are just a starting point, and the specific codes used may vary depending on the patient’s insurance plan and the services provided. It’s important to verify the correct codes with the insurance company and ensure accurate billing to prevent any potential issues with reimbursement.

Frequently Asked Services Questions

 

Verification of Benefits

What is the response time when a facility submits a Verification of Benefits to Axis?

Axis has a team consisting of 9 Claims Representatives that also verify benefits for our facility. As soon as we receive a Verification of Benefits, within minutes a claims representative will be on the phone with the insurance company. We believe in very thorough verification of benefits processes. We will cross reference all information to ensure accuracy before returning the Verification of Benefits to your facility.

On average a thorough Verification of Benefits will take about 45 minutes or less.

What can my facility expect when Axis verifies benefits for a patient?

You can expect the Axis to take every pre-caution to ensure accuracy of benefits for every level of care. We understand how paramount the Verification of Benefits process is to the entirety of billing processes. If the Verification of benefits its not done thoroughly it will have a domino affect for the patients authorizations and billing processes. We not only give you the benefits that were quoted to the Axis team, but we also provide a benefit summary which is more comprehensive.

We also provide additional information on the insurance carrier or policy and let you know what our experience has been with the insurance carrier or the specific policy. We want to make sure you understand the benefits to the fullest in order to best help your patients.

Utilization Review / Authorizations

What is a Utilization Review / Authorization?

There are 2 components of Authorizations. The first is the Pre-authorization, this process is typically done using a very specific format which Axis has refined over the years to cater to the insurance companies needs. When a patient arrives at your facility we request that your clinician fills out the entirety of the pre authorization from which we provide to you.

Once this is complete you will submit the form to the Axis Authorization team and we take it from there. As soon as we receive the authorization from the insurance company, we then notify the representatives at your facility to let them know when we will need a Utilization Review to obtain further authorization.

The Utilization Review is done anywhere from every 3 days up to being on a monthly basis. This is dependent on the level of care in which the patient is at as well as the complexity of each case. We also supply your facility with a Utilization Review template in which your clinicians will fill out and again submit to the Axis Authorizations Team. The authorizations team will then contact the insurance carrier using the provided information and obtain further authorization.

What are the benefits of having your team manage authorizations for our facility?

The Axis authorizations team is comprised of clinicians who are specially trained to work with insurance carriers. They speak the language of the insurance companies and spend countless hours researching and staying up on the changes in the substance abuse and mental health field. They also are very familiar with the medical necessity criteria for each insurance carrier.

This allows the authorizations team to advocate  for your patients and maximize authorizations for your patients.

The Axis authorizations team does not take no for an answer when it comes to helping a patient receive treatment. We have specific policies and procedures that the authorizations team follows to manage any denials and have set a new standard of overturning denials. Above this all of the individuals in our authorizations department are extremely passionate about helping individuals receive the treatment they need.

Claims Processing and Management

How long does it take to receive payments after submitting claims?

The turn around time for claims to be processed and paid is highly dependent on the insurance carrier. Axis made an analysis for the past 6 months and found that the average time it takes to receive payment on a claim is roughly 45 days from the time it is submitted to the insurance company.

Does Axis help with appeals and denials of claims?

Yes, Axis manages all aspects of claims processing including denials management. We have very defined processes for appeals and managing denials. Similar to the authorizations team, we do not accept denials lightly. We  appeal the denials using specific denial management tools to ensure that we are fighting the denial until there is some type of determination. Our staff is specially trained in managing denials and understand the insurance processes thoroughly.

This allows us to successfully overturn many denials and receive payment on claims.

Axis is follows up on all claims every other week. This allows us to catch any problems with claims processing in a very swift manner. While many 3rd party billing companies submit claims and wait for remittance from the health insurance carrier, which can be 30-60 days from the time a claim is submitted, we take a very proactive approach to the claims management processes.

By utilizing our expertise and our diligent approach we will know if a denial happens before any remittance is submitted to your facility as well as have the ability to manage claims on our end without needing to contact your facility to assist with these processes.

 

To obtain accurate and up-to-date information regarding ChampVA billing codes, condition codes, occurrence codes, and value codes for behavioral health RTC, PHP, and IOP claims. It can be best to consult the official resources provided by ChampVA.

Every plan is different, and they can provide you with the most current and accurate information related to their billing and coding requirements.

What are the ChampVA Billing Codes for Behavioral Health

ChampVA follows the standard coding systems for billing behavioral health services. The most commonly used coding systems for behavioral health services are the Current Procedural Terminology (CPT) codes and the Healthcare Common Procedure Coding System (HCPCS) codes. Here are some common CPT and HCPCS codes that may be used for billing behavioral health services with ChampVA:

CPT Codes:

  • 90791: Psychiatric diagnostic evaluation
  • 90832: Individual psychotherapy, 30 minutes
  • 90834: Individual psychotherapy, 45 minutes
  • 90837: Individual psychotherapy, 60 minutes
  • 90846: Family psychotherapy without the patient present
  • 90847: Family psychotherapy with the patient present
  • 90853: Group psychotherapy
  • 96101: Psychological testing evaluation services
  • 96118: Neuropsychological testing
  • 99213: Evaluation and management (E/M) service for an established patient, 15 minutes

HCPCS Codes:

  • H0031: Mental health assessment, by a non-physician
  • H0035: Partial hospitalization (PHP) services, per diem
  • H0036: Community-based psychiatric rehabilitation and support, per 15 minutes
  • H2011: Crisis intervention, per hour
  • H2035: Alcohol and/or drug services, group counseling
  • H0004: Behavioral health counseling and therapy, per 15 minutes
  • S9484: Behavioral health, counseling and/or therapy provided via synchronous telecommunication
  • T1015: Mental health case management

The specific codes used for billing behavioral health services may vary depending on the nature of the service provided, the duration, the level of care, and other factors. Consult the most recent version of the ChampVA provider manual or contact ChampVA directly for the most accurate and up-to-date information on billing codes specific to their program.

How to become credentialed with ChampVA as a healthcare provider?

Providers need to go through a credentialing process. Here are the general steps involved:

  1. Determine eligibility: First, ensure that you meet the eligibility criteria to participate as a provider in the ChampVA program. This typically involves having the necessary licenses, certifications, and qualifications to provide the specific healthcare services covered by ChampVA.
  2. Complete the application: Obtain the provider application form from ChampVA. You can typically find the application form on their official website or by contacting their provider enrollment department. Fill out the application form accurately and completely, providing all the required information.
  3. Gather required documentation: Along with the application form, you will need to submit various supporting documents. These may include proof of your professional qualifications, such as copies of licenses, certifications, and educational degrees. You may also need to provide documentation related to your professional liability insurance, practice locations, and other relevant details.
  4. Submit the application: Once you have completed the application and gathered the necessary documentation, submit the application and supporting documents to ChampVA according to their specified instructions. This is typically done either electronically or by mail, depending on their preferred method.
  5. Follow up and respond to inquiries: After submitting your application, be prepared to respond to any additional requests for information or clarifications from ChampVA. They may contact you if they require any further documentation or have questions regarding your application.
  6. Await review and decision: The ChampVA provider enrollment department will review your application, verifying your credentials and evaluating your eligibility to participate in the program. The review process can take some time, so it’s important to be patient.
  7. Notification of credentialing decision: Once the review process is complete, you will receive a notification from ChampVA regarding the status of your credentialing application. If approved, you will be provided with further instructions on the next steps to become an enrolled provider with ChampVA.

Specific requirements and processes for credentialing with ChampVA can be dependent on each provider. Providers can also contact the enrollment department directly to obtain the most accurate and up-to-date information on their credentialing process and any specific requirements they may have.

Substance abuse treatment is an important aspect of healthcare that helps individuals overcome addiction and lead healthier, more fulfilling lives. However, the cost of treatment can be a barrier for many people, which is where insurance comes in. Insurance can help cover the cost of treatment, making it more accessible to those in need.


Further, the process of billing insurance for substance abuse treatment can be complex and confusing.

Here is an overview of substance abuse insurance billing and what you need to know:

  1. Check your coverage: The first step in substance abuse insurance billing is to check your insurance policy to see what is covered. Most insurance plans will cover some or all of the cost of substance abuse treatment, but it’s important to understand the specifics of your coverage. This includes the type of treatment covered, the amount of coverage, and any exclusions or limitations.
  2. Choose an in-network provider: To get the most out of your insurance coverage, it’s best to choose an in-network provider. These providers have agreed to accept the insurance company’s payment rates, which can help lower your out-of-pocket costs.
  3. Gather documentation: In order to bill your insurance for substance abuse treatment, you will need to provide documentation of your treatment. This may include receipts, treatment plans, and progress reports. It’s important to keep thorough records of your treatment to ensure that your insurance claim is processed correctly.
  4. Submit a claim: Once you have all of the necessary documentation, you can submit a claim to your insurance company. This can typically be done online or by mailing in a paper form. Be sure to include all relevant documentation with your claim.
  5. Follow up on your claim: It’s important to follow up on your insurance claim to ensure that it has been processed and that you are receiving the coverage you are entitled to. If you have any issues with your claim, you can contact your insurance company or provider for assistance.

Once an individual has chosen a treatment facility, the facility will typically handle the billing process on their behalf. This may include verifying insurance coverage, submitting claims, and negotiating with the insurance provider on behalf of the individual. It is important for individuals to stay informed about the status of their billing and to address any issues or discrepancies that may arise.

There are several factors that can impact an individual’s substance abuse insurance billing, including the type and length of treatment received, the specific services provided, and the individual’s insurance coverage. It is important for individuals seeking treatment to be proactive in understanding their insurance coverage and working with their treatment facility to ensure that they receive the coverage they are entitled to.

Overall, substance abuse insurance billing can be a complex and confusing process, but it is an important aspect of seeking treatment for substance abuse. By understanding their insurance coverage and working closely with their treatment facility, individuals can help ensure that they receive the coverage they need to support their recovery journey.

Insurance is an important step in getting treatment for those in need. By understanding your coverage, choosing an in-network provider, and submitting a complete and accurate claim, you can help ensure that you get the coverage you are entitled to.

UBH/Optum discontinuing Out of Network Benefits …and it doesn’t stop at behavioral health services…medical services might be equally affected. 

As of July 1, 2021 UBH/Optum has notified some providers about changes to UBH/Optum plans that apparently include, among other changes,  the decision to exclude members’ out-of-network  benefits for services located outside of the member’s plan’s  service area. Notably, a “Fully Insured” plan according to Optum is a plan wherein the insurer pays for the services  and the member is not covered by a self-funded employer plan.. The change will apply to medical and behavioral health services. Keep in mind, services are already subject to prior authorization, and this will add one more barrier to a growing number of barriers to care.

The Notice specifically calls out behavioral health exclusions for non-emergent, sub-acute  inpatient or outpatient services received at any of the following facilities:  

• Alternate Care Facility – PHP or IOP  

• Freestanding Facility – Psychiatric or Substance Use  

• Residential Treatment Facility – Psychiatric or Substance Use  

• Inpatient Rehabilitation Facility – Psychiatric or Substance Use  

While the Notice appears to have been directed to in-network (“INN”) providers, the changes we shared above  would not affect services provided by INN providers who evidently can continue to admit and treat members of  Fully Insured plans regardless of geography. Indeed, the Notice specifically advises INN  providers that they may be asked to accept Optum members who are currently at out-of-netowork (“OON”) facilities that will no longer be covered at those facilities once this change in coverage goes into effect. 

optum out of network benefits
This Optum decision could lead the way for other carriers to force providers to go in-network

Despite Optum’s couching this change in policy as a “quality and cost-share” issue, it seems  more likely to be strictly a cost-cutting measure, particularly given that the change applies only  to Fully Insured plans where Optum is “on the hook” for the cost of care, but not to self-funded  employer-plans where Optum’s role is only to serve as an administrator of claims that ultimately are  paid by the self-funded plans themselves. 

Sounds convenient, doesn’t it? It also sounds like a barrier to much needed care. 

As for providers, especially in the behavioral health space, they typically are either unable to  secure contracts with payors like Optum despite efforts to do so, or they opt to stay out-of network because they do not want to accept the lower reimbursement rates demanded by the  major payors when contracting to be an INN provider. 

We fear that Optum’s new policy is a violation of Mental Health Parity laws. While on its face the Notice appears to apply to both medical and behavioral care, in practice, there likely will be a disproportionate impact against behavioral health providers, especially residential treatment centers (“RTC’s”). 

Comprehensive and accurate mental health coding is vital as behavioral and mental health claims are on the rise.

We frequently find ourselves progressively adapting to learn nuances with each insurer differently to avoid claim delays or denials. Making improvements accordingly helps make the overall patient experience a lot smoother for the facility’s care team, the engagement with the insurer, and of course the patient’s family.

Nowadays, entities like behavioral health facilities are far more prone to denials and payer audits more than any other medical coverage a patient may have. This puts mental health services at risk as the insurers concentrate on the coding accuracy and things like the duration of services rendered.

The insurance carriers are all about its utilization. They perform plenty of data mining, so all mental health providers regardless what profession they are like psychotherapist, licensed clinical social worker, physician, licensed mental health counselor, or non-physician practitioner, all require that documentation be accurate to avoid delay or denial of claims.

What are CPT codes?

For those who are reading this and not familiar with how claims are paid, they all start with a medical code that can be billable to the insurance carriers.

CPT (Current Procedural Terminology) codes are extremely important and are used for payment for services, especially when it is to be reimbursed by the insurance companies. The American Medical Association developed the CPT codes and assigned from surgical to diagnostic codes for medical providers to use for their patients.

What type of documentation do insurance carriers want to see from providers to avoid any scrutiny?

  • Patient’s diagnosis. This is critical as the insurance carriers use this information to determine if therapy is medically necessary and if the specific therapy type is warranted. For instance, insurers may question the validity of therapy sessions provided to a patient with a neurological or cognitive deficit or a chronic brain injury when a drug intervention may be more appropriate.
  • Therapy type. Physicians likely provide supportive therapy while other mental health providers may provide an array of options, for example, cognitive behavioral therapy, psychoanalysis, or insight-oriented therapy. This is important when initially verifying coverage and benefits, and specifying therapy type, facility, etc… to ensure it will be a billable service provided.
  • Therapy goals: What treatment plans are set in place for the patient, short and long term?
  • Progress reports: Is the therapy being provided benefiting the patient?
  • Duration of sessions: What is the therapy start and stop times, to the exact minute.

How to know what psychotherapy codes to use?

As of 2013, CPT codes distinguishes between physician and non-physician providers performing psychotherapy services. Physician and Non-physician providers doing psychotherapy services use CPT codes such as 90832, 90836, or 90837, but all are based on the duration of the session. Aside from coding these services accurately, they should always be accompanied with documentation supporting the time spent providing the psychotherapy service.

help with insurance billing for drug rehab

Coding tips when billing for mental health services.

  • Clearly document the time spent and benefits of the psychotherapy. The carriers want to see that a physician billing for psychotherapy is actually doing a therapeutic intervention. Spending extra time talking with the patient does not translate to a billable psychotherapy service. Generally, insurance carriers are worried about over-use of psychotherapy services, particularly if it appears the patient gets no benefit or shows no progress. If in some cases the patient is resistant to psychotherapy interventions or is not taking sessions to heart, it’s not going to benefit them.
  • Documentation justifies any sessions extending beyond 45 minutes. The carriers want to see and know why time extension was necessary. Without proper supporting documents, claims may receive lower reimbursement or even denial.
  • Use group therapy (CPT code 90853), when appropriate. Group therapy is great for patients because they can meet and talk with others with similar problems and usually looked at as very beneficial. Carriers may also consider patients who go through bereavement counseling during a public tragedy or for a court-ordered group setting counseling session for whatever reason valid to use this code.

Documents that are compliant and accurate coding helps providers in avoiding delays and denials. Staying up to date with best practices seems to be a never-ending task, however,  we are glad we could share some insight with you about the significance of correctly utilizing CPT codes when billing for mental health services.

Having an effective revenue cycle management in place for your center is essential in optimizing performance and margins. From the first contact with patients, such as verification of benefits and authorization preparation, to efficient service coding and billing, to finalizing and collecting on all claims. 

Throughout the whole process, there are key elements in ensuring success with revenue collections that we will cover in this article. Finding the right people to facilitate and function technology, getting real-time eligibility and service authorizations, using data to build a successful game plan for claims denials. 

Finding the right people to facilitate and function technology: Billers are in high demand now days and technology tools continually advance in ways of making jobs and tasks streamlined and accommodating for centers and their treatment teams, however, you still need people with the ability to use the tools available to them. They have to be able to use those tools effectively while understanding the billing and collection process behind them. Payers advise that we use their online tools to obtain the information we need, so it is very important to utilize those tools available to prevent delays or denials. A solid process and accountability of each person involved, maintenance training, and incentives are all factors in maximizing your revenue cycle management.

Getting real-time eligibility and service authorizations: More than 20% of denied claims are usually caused from an authorization issue. Prioritizing real-time verification of benefits and authorizations has to be the main ingredients to ensure success from beginning to end. Many payers allow the ability to get this information online also, making it even more convenient when you don’t have to call someone and wait on hold forever. Create structured processes, that is frequently updated, for prior authorizations for each payer including any benefit coverages or medically necessity requirements. 

Using data to build a successful game plan for claims denials: The only way to prevent claim denials is to use data from denied claims to improve the process. Understanding the how, why, and what caused claims to be denied, you can adjust accordingly to prevent it from happening again with future claims, resulting in an improved revenue cycle management process. There are cases where it may seem impossible to overturn a denied claim, but if you do your due diligence, respond in a fast and timely manner, there’s a good chance you may surprise yourself. Exhaust all options before archiving denied claims. 

These are just a few ways to possibly help increase your insurance reimbursements for your patients and decrease claim denials. This is so beneficial to everyone involved, from the insurance companies to the staff and treatment team at the center, and most importantly, the patient and their family. 

I would like the opportunity to hear what has worked for your center in the past or present? What obstacles do you frequently run into when dealing with your insurance claims? I look forward to discussing more ways to improve. 

Did you know that nearly one out of every five Americans had a mental illness last year? Denying coverage is now being looked at deeper than just a financial issue, as some see it as a human rights issue.

Families are suffering from the strict system placed on behavioral health insurance processes. A system that fails the needs of people who need it the most, because of not meeting insurance company’s, “medical necessity”, clause.

Without a reasonable doubt, this is more than a concern for so many Americans who suffer from behavioral health illnesses and can’t seem to get the adequate treatment needed to overcome this difficult roadblock.

A psychiatrist once said,

“Before I decided to specialize in psychiatry, I assumed a person in need of mental health care would have the same access to treatment one has for medical conditions like kidney stones, pneumonia or seizures. Instead, mental health patients and their providers face a mountain of bureaucratic obstacles that other patients are spared.”

Imagine being a doctor, and having to tell someone or even a child who desperately needs treatment, that they aren’t considered depressed enough, or their presenting conditions do not meet the most critical states of mental illness in order to be treated.

With adolescent mental health illnesses on the rise, this has to be one of the most ignored issues that we face in America today. According to the new report, diagnoses of “Major Depressive Disorder”,  have risen to over 30 percent since 2013, and now affects an estimated 9 million commercially insured Americans.

Teen depression rates are increasing so rapidly, if we don’t figure out a better solution, we will be headed for an array of consequences. The Centers for Disease Control and Prevention estimates there were 72,000 deaths from opioid overdoses last year and more than 43,000 suicides reported in 2017.

Nowadays the requirement to even be admitted into a psychiatric facility is set so high, it can be very frustrating when attempting to get prior authorization for treatment. Even if patients have just attempted suicide, shockingly many insurers still require prior authorization by phone before they can step foot inside of the facility.

“Even in spite of the fact that we’re in the midst of the biggest public health crisis of our time of overdose and suicide, we as a nation have yet to come to grips with this in the way that it needs to be,” – Former congressman and mental health care advocate Patrick Kennedy. 

For any other medical hospitalization, nothing is really required and the insurers trust the judgment of the providers. Not the same for psychiatric hospitalizations and treatment centers. In the U.S., denials for mental health care occur three times as frequently as denials for general medical care.

The process of finding and funding adequate mental health treatment is a very daunting task, and most times insurers will simply deny treatment initially knowing that most people are going through so much that will won’t challenge denials of care, leaving them feeling lost and confused and only adds to the stress they are already dealing with.

It’s time to make mental health illness a priority in not only fighting the stigma but also the discrimination set forth from the insurance companies. This system continues to get worse and totally does everything they can to stop treating those who need it, simply based on the fact that they are not considered depressed enough, or suicidal enough to please their extreme criteria. Ask yourself, why isn’t mental health illnesses being looked at as serious as cancer, diabetes, or cardiovascular diseases?

It’s quite frustrating when just 10 years ago, a law passed called the  Mental Health Parity and Addiction Equity Act, also known as the Federal Parity Law. The law requires most insurers to cover illnesses of the brain, such as depression or addiction, no more restrictively than they cover illnesses of the body.

“There are still tons of roadblocks on the policy side and, frankly, in spite of the fact Congress thinks they’ve appropriated some gargantuan amount of money, it still represents less than one-fifth of what we were spending on HIV/AIDS during the AIDS crisis when we were losing far fewer people than we’re currently losing today,” – Patrick Kennedy

In a recent study conducted by a private research company and Georgetown University, researchers found the following listed below.

  • Insurers regularly denied coverage to people with pre-existing mental or substance use conditions;
  • Insurers imposed a 20 to 50 percent increase in premiums for people with a history of mental health or substance use conditions;
  • Insurers offered superficial coverage that did not meet essential needs; and
  • Insurers actively created barriers and limited access to mental health and substance use treatment.

The only way we can see any change is by standing up and speaking out on unjust insurance denials and registering a complaint with your health plan. The more we do this, we can help pressure elected officials, insurance commissioners, and the attorneys general to enforce federal and state parity laws in favor of the patients who need the attention and treatment their insurance plan should be covering.

Nothing will ever change if we don’t speak up and hold insurance companies accountable. We must demand equality for those with mental health and addiction challenges. We cannot stand idly by while insurance companies break the law, at the expense of American families.

Help for Mental Illnesses. Get Immediate Help. If you are in crisis and need immediate support or intervention, call, or go the website of the National Suicide Prevention Lifeline (1-800-273-8255). Trained crisis workers are available to talk 24 hours a day, 7 days a week.

Have questions or need help with insurance claims and or denials, we are always here to answer or help in anyway possible.

These simple fixes could save thousands of dollars and dozens of headaches. Work them into your billing processes!

Is your treatment center experiencing financial difficulties? There are many billing errors that can cause claims to be denied. Payments being delayed, incurring fines, and revenue loss can all happen due to errors not being caught before submitting claims. So before you start sending your claims out, beware or the most common mistakes.

 

  1. Having a brain lapse and forgetting to verify insurance

Believe it or not, the top reason why most claims are denied is because there was no initial verification of benefits and coverage. We all know insurance can change for whatever reason. So it is crucial that the provider verifies it every time services are rendered. When you don’t verify insurance properly, things like are overlooked like.

  • Members coverage may be terminated
  • The service isn’t even authorized in the first place
  • The plan benefit doesn’t cover the service being rendered
  • The Lifetime Maximum benefit has been met

 

  2. Inaccuracies in the Patient’s File

You would be surprised how something as simple as a patient’s name being misspelled, or having the wrong date of birth, or is this the patient relationship status to the insured correct, also using a policy number that is invalid can cause claims to be denied upfront. However there are some pieces of information that aren’t so clear and easy to notice like.

  • The claim requiring a group number to be entered
  • Making sure the diagnosis code matches with the procedure code
  • If there are multiple insurances, making sure the primary insurance is right for coordination of benefits

You don’t want to have to miss one of these simple pieces of information — making the claim go from say a 1-2 week turnaround, to a 30 to 45 days before the claim is paid.

3. Not using the Correct Diagnosis or Revenue/HCPC Codes on Claim

Like stated above making sure the diagnosis and procedure codes match are very important, but more importantly you want to be sure the codes being used are actually correct. This is how the insurance company knows the symptoms, disorders and how they are being treated by the facility. Incorrect information can result in a immediate denial of the claim for not being medically necessary, or it doesn’t match the authorization given for treatment.

Couple of things to consider as to why the wrong diagnosis or procedure code could be submitted resulting in denial.

  • Your Coding books are out of date and you’re using old protocols that have been revised. They can be pricey but is it really worth losing revenue on avoidable denial errors?
  • You might laugh, but if you handwriting is not up to par and causing claims to be denied because of horrible penmanship, you should really consider switching from paper claims to a electronic submission.

 

4. Duplicate Billing

Duplicate billing is just what it sounds like, billing for the same service or treatment  on more than one claim. It can also be considered as billing for a procedure that wasn’t even performed in the first place. It is very key to perform Chart audits for all patient’s to ensure claims are being billed out correctly. Ultimately you want to try and limit this to none, as facilities are fined each year for these small mistakes and considered as committing fraud. Ouch!

 

5. Misrepresenting Level of Care

This occurs when you the level of care is incorrect in order to receive a higher reimbursement rate from the insurer, also referred to as up-coding. Claims are looked at in fine detail to it’s better to just not do, or once again it will deny and stall the claim payment.

The Secrets to Claims Follow Up

First things first… “Hello Mr. Insurance Company, I need…”

Speedy resolution of your behavioral health facility claims all depends on effective collections follow up. Follow up on all claims should begin as soon as 7 to 10 days after your claim has been submitted to the insurance company.  Pursuing to get claims paid immediately will not only reduce the time you spend on accounts receivable but will also increase cash flow.

A staff well trained in insurance reimbursement protocols as well as negotiating and customer service is imperative in order to have the most efficient revenue cycle management possible. A key indicator of a competent staff is the ability to have crossover expertise in verifying of benefits, claims submissions

Always be well prepared. Research the patient’s account thoroughly to ensure you’re asking the proper questions. You’ll want to have all the information that you will need at your disposal once you get a insurance representative on the phone. Key notes are things like:

  • Date of birth (DOB)
  • Address
  • Policy number
  • Dates of service (DOS)
  • Amounts billed, etc.

It is very important to get as much as information for documentation from the call as possible. Ask the customer service representatives (CSR) information once the call is complete:

  • Name
  • Extension number (some companies use an employee id number),
  • Call reference number

This is critical when making follow up calls on situations that may take more than one call.

But when you can, try to get this information upfront – often times there are random disconnections from the carrier side. Obviously it is easier to pick up where the last call was ended if there is some reference to start from.

The “Ten Commandments of Insurance Billing Questions”

The ultimate objective is to find out if a claim has been processed and if a payment can be expected. A key indicator that there could be a problem is that it has been over a month since a claim was submitted. If this is the case, the CSR should be able to outline what happened and how to rectify the situation in order to get the claim processed. Be sure you are asking enough questions of the right questions. Doing this on every call and you get closer to obtaining payment from the insurance company. I call this the, “Ten Commandments of Insurance Billing Questions.”

  • Can I get an on-shore representative (OSR)?
  • What is the expected payment date?
  • Is the claim through the clearing house, at the payor, in processing?
  • What is the expected allowable amount?
  • What’s all the information on the payment including the check number?
  • Is there an issue with the claim or what is the reason for the lengthy reimbursement process?
  • Why is the claim still processing or “under review” – what are they reviewing?
  • Can I email or fax medical records or do they need to be mailed?
  • Can this claim be expedited – can I speak with a manager?
  • Why is the claim paying so little, is there an issue with pricing?

This is just like anything else in life – you may not be getting the truth. Advocate!

Customer support for most carriers have call time frame quotas that they try to maintain. They will try to get off the phone as soon as they can without prompting you to gather important information from them. You have to be proactive and assertive with your efforts on these claim calls. Make sure you get all the information you called for, and if something is not making sense, hold them accountable to find the answer or get a manager on the line who can.

An example of this is when a claim payment is being delayed or withheld and the customer service representative does know why, or gives you a very invalid reason for it. They will then just send the claim back in for “reprocessing” or send an “inquiry” in on it. This is not sufficient enough because they will then tell you to check back in 30 days to make sure it processed. Obviously no one wants to wait another 30 days to receive reimbursement.

Do not take “no” for answer. Get a manager or supervisor on the phone who can tell you exactly what happened and how it will be rectified.

When you do finally get someone on the line who has some answers, dig deeper. Make sure there are no irregularities with any other claims or payments that may delay the process.

Remember these people you are talking to are just regular people with regular jobs. Do you best to be kind and empathetic while also being assertive. If you can build some understanding and rapport on both sides, often times they will be able to go the extra mile and break their internal protocols to help you out.

What is Next? Well this is where you make it happen!

So step one is done and you have the information needed on the status of the claim to figure out how to proceed from there. The “mess-up” the carrier has done in order to slow down the reimbursement process will determine your next move.

The absolute first check point is to make sure there is an active policy and there were in fact benefits available. Submitting claims without that is a complete waste of time.

    • Claim did not make it through the clearing house and there is nothing in the system.
    • Lack of clinical information – medical records missing.
    • Coordination of Benefits (COB) is needed on the primary insurance plan.
    • Missing demographic or ID information missing from member.
    • Prior authorization is missing or was not obtained upfront.
    • A Referral from a Doctor did not get submitted.
    • Random lack or wrong Information on claim.
    • Medical necessity for RTC level of care is not meeting the criteria of the plan.

Well you may need information or help from the patient?

Patients are trying to get better at this point, it is difficult enough with everything going on to truly make themselves the only priority. Unless you have no other option, don’t go this route.

Here are a few ways to handle this step:

  • Billing the patient or family directly. If you are not able to get anywhere with the insurance carrier as a provider, sometimes the member will have much better luck. Insurance companies offer different customer support (usually more robust) to members compared to the provider side. You can send the bill to them and they can submit it themselves.
  • Have a conversation with the patient on how to self-advocate. If claims are being held up or not paid or denied out right when they should be paying, you can ask the member to call in and attempt to get answers. Give them call dates, billed amounts, reference numbers, and documentation if needed so they can have a more streamlined call. Also give them a heads up on hoops they will have to jump through and some of the tricks to getting the right person on the phone (managers in the US!)
  • Get the patient on a call and then call the insurance provider. Insurance carriers do the best they can and they have multiple systems and customer support departments that all have to interact. Sometimes the member side and the provider side will get contradicting information. There is nothing wrong with getting everyone on the call at the same time and sorting things out.