Category: Health Insurance

Did you know there are multiple types of depression? There are signs and causes, as well as a variety of treatments. Finding the right treatment and figuring out how to submit claims for insurance reimbursement can be quite complicated as well.

Understanding all the Types of Depression

Depression is a mood disorder characterized by persistent feeling of sadness and a general loss of interest in things that would normally bring you some pleasure. The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-V) gives some insights for understanding depression and according to the criteria, you may be having a depressive episode if you experience these episodes for at least a few weeks.

There are several classifications of depression. There is some distinction based on the cause of the type of depression and the signs and symptoms. Seven of these depression types are as follows

  1. Major Depressive Disorder (MDD)

Also known simply as major depression or clinical depression, this is indeed the classic form and most common type of depression.

To be diagnosed with major depression, you must have 5 or more of the following symptoms

  • Feelings of sadness
  • Feelings of worthlessness
  • Feeling “empty” and hopeless
  • Feelings of guilt
  • Irritability
  • Changes in appetite
  • Loss of energy and fatigue
  • Thoughts of suicide and death

There are two subtypes of major depressive disorder, namely atypical depression and melancholic depression. People with melancholic depression tend to ruminate over some guilt-ridden thoughts and have trouble sleeping. This subtype is common among seniors. On the other hand, atypical depression is more common among young adults. It presents with feelings of anxiety and irritability and people with atypical depression tend to sleep a lot.

  1. Persistent Depressive Disorder (PDD)

Also known as dysthymic disorder or dysthymia, people with this type of depression have depression symptoms lasting for at least 2 years. A child or teen may be diagnosed with PDD if their symptoms last for a year or more.

While the low moods and other symptoms last longer, they are not as severe or as intense as with other types such as major depression. To be diagnosed with PDD, you must have two or more of the following symptoms

  • Sleep problems
  • Low energy and fatigue
  • Low self-esteem
  • Feelings of hopelessness
  • Change in appetite
  • Poor concentration
  • Difficulty making decisions

  1. Major Depressive Disorder with Seasonal Pattern

 Commonly known as seasonal depression, this type of depression was previously defined as seasonal affective disorder (SAD.) This is the recurring kind and common in the winter.

Experts have proposed that seasonal types of depression can be tied to the lack of natural sunlight. Symptoms usually last from early winter through to the spring time. Research has also pointed to an imbalance of serotonin and an overabundance of melatonin, which is the sleep hormone.

There is a less common type of seasonal depression referred to as summer-onset seasonal depression. As the name suggests, it occurs in the summer and spring.

 This type of depression is diagnosed after at least two years of recurring symptoms. Symptoms of major depressive disorder with seasonal pattern are such as are common with other types of depression and include

  • Feelings of anxiety
  • Lack of energy and general fatigue
  • Increase in appetite and weight gain

  1. Bipolar Disorder

This type of depression is also called bipolar depression or manic depression. People with bipolar depressive illness experience extreme mood fluctuations as well as their sleep patterns, energy and general behavior. You may feel hopeless and lethargic one day and bursting with energy and feeling euphoric the next.

You must experience at least one bout of mania to be diagnosed with bipolar disorder. For some, these extreme fluctuations can happen up to several times a week, and for others, it can be quite infrequently, such as once or twice a year.

A difference in severity of the manic symptoms is what distinguishes between bipolar 1 and bipolar 2 disorder. The mania is more severe in bipolar 1.

  1. Psychotic Depression

Psychotic depression is characterized by symptoms of both depression and psychosis. People with this type of depression experience depressive episodes that are so severe that they experience psychotic symptoms.

To be diagnosed with psychotic depression you must have experienced a depressive disorder lasting for at least two weeks accompanied by psychotic symptoms, namely hallucinations and delusions. The content of these hallucinations and delusions are usually consistent with or involve depressive moods such as guilt.

  1. Peripartum/Postpartum Depression

Pregnancy puts many women at an increased risk of depression. Depression during this time is often a combination of several factors.

Baby blues are quite common following birth as you adjust to a new baby. These blues are different from peripartum depression which lasts longer and has a profound impact on the relationship you will have with the new baby, spouse and other family members.

Symptoms of peripartum depression usually appear within a week to a month after delivery. Unlike the baby blues that usually go away without treatment, treatment is necessary for postpartum depression.

Symptoms include

  • Extreme moods ranging from anger and anxiety to hopelessness
  • Irritability
  • Crying
  • Restlessness
  • Fatigue
  • Change in appetite and weight
  • Lack of concentration
  • Rumination
  • Unwanted thoughts, including extremes such as how to self-harm or harm the baby
  • insomnia

Some women will experience depression throughout their pregnancy and not just after delivery. Perinatal depression is the inclusive term doctors use to describe depression that may occur during the pregnancy and after delivery.

  1. Premenstrual Dysphoric Disorder (PMDD)

This disorder is the more severe form of premenstrual syndrome (PMS) and affects up to 10% of women who are of childbearing age. Symptoms of PMDD include irritability, anxiety and general sadness.

These symptoms may start to show after ovulation and throughout that window of time before menstruation starts.

Scientist believe that PMDD is as a result of abnormal sensitivity to the hormonal changes that occur during the menstrual cycle.  

billing codes for depression

Depression Causes and Risk Factors

There are several causes and risk factors for depression including the following

  1. Brain Chemistry Imbalances

Neurotransmitters such as dopamine , norepinephrine and serotonin play a big role in mood regulation experts believe that imbalances in these brain chemicals can cause depression. Its therefore no surprise that some of the medications used to treat depression target restoring the balance in these levels of brain chemicals.

  1. Physical Health and Medical Conditions

People suffering from a chronic illness are at a higher risk of experiencing symptoms. Conditions such as sleep disorders, cancer, multiple sclerosis are top among the list of medical conditions that are a risk factor for depression.

The toll of a physical health condition can also impact your mental health. Again, some illnesses such as thyroid disorders cause symptoms that are similar to those of depression.

  1. Genetics and Family History

You are at a greater risk of developing depression if there is a history of depression and other mood disorders in your family. Family studies have shown the strong connection between depression and genetics. That being said, researches are yet to pinpoint the exact genes that affect and increase the risk of depression.

  1. Risk Factors Related to Lifestyle

From poor nutrition to stress and substance use, there are several lifestyle choices that can put you at a greater risk of suffering from depression. While you may not be able to change other risk factors such as genetics and you have little control over brain chemistry, you have full control over these lifestyle choices that are a risk factor.

Are Depressed Brains Different?

The thalamus, amygdala and hippocampus are the main areas of the brain affected by depression.

Research has shown that a depressed brain has a smaller hippocampus. It gets smaller with every bout of depression. Experts believe that stress, which plays a huge role in depression causes this shrinkage by suppressing the production of new nerve cells in this part of the brain.

A depressed brain also has more activity in the amygdala. This is the part of the brain associated with emotions including pleasure and anger. It gets activated when someone has or recalls an emotional experience, such as the loss of a loved one.

Experts believe that people with depression have some of the functionality of the thalamus impaired. This is on account of impaired nerve cell growth in this brain region.

Which Type?

A diagnosis by a doctor is the sure way to tell which type of depression you have. Diagnosis may involve

  • A psychiatric evaluation done against the DSM-V criteria.
  • Physical examination and blood tests to rule out other medical conditions

Get in Touch

Treatment plans for depression involve psychotherapy and medication. Noticed the signs and symptoms of depression?  contact us for a clinical diagnosis and effective treatment plan.

How to Bill Insurance with for Depression and Other Mental Health Diagnosis

Below are some of the more common F codes you would need to submit claims to insurance.

F41.1 – Generalized anxiety disorder
F43.23 – Adjustment disorder with mixed anxiety and depressed mood
F41.9 – Anxiety disorder, unspecified
F43.22 – Adjustment disorder with anxiety
F43.10 – Post-traumatic stress disorder, unspecified
F33.1 – Major depressive disorder, recurrent, moderate
F43.20 – Adjustment disorder, unspecified
Z63.0 – Problems in relationship with spouse or partner
F43.21 – Adjustment disorder with depressed mood
F34.1 – Dysthymic disorder
F32.9 – Major depressive disorder, single episode, unspecified
F90.9 – Attention-deficit hyperactivity disorder, unspecified type
F32.1 – Major depressive disorder, single episode, moderate
F90.0 – Attention-deficit hyperactivity disorder, predominantly inattentive type
F41.0 – Panic disorder [episodic paroxysmal anxiety] without agoraphobia
F33.0 – Major depressive disorder, recurrent, mild
F33.2 – Major depressive disorder, recurrent severe without psychotic features
F43.25 – Adjustment disorder with mixed disturbance of emotions and conduct
F40.10 – Social phobia, unspecified
F42 – Obsessive-compulsive disorder

There are essentially four separate levels of care that a patient could be getting treated with any of these diagnosis. Residential/inpatient (RTC), Partial Hospitalization (PHP), Intensive Outpatient (IOP), and Routine Outpatient (ROP).

There are specific tasks to all of these in reference to getting insurance reimbursement through the entire authorization and claims submission process. Please reach out to 541-ASK-AXIS for questions on this.

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”). 

Insurance carriers all look at eating disorder treatment differently. Submitting claims or billing for eating disorders can be complicated.

Navigating an insurance billing for eating disorders can be a nuisance if you do not know what to do or where to “touch.”  One of the main obstacles to treatment for facilities and outpatient programs helping individuals with eating abnormalities is the cost of the treatment.  Some residential treatment centers can cost up to $30,000 a month. Clearly with everything that has happened in 2020-2021, a crucial driver in where someone chooses to get treatment is the ability to accept insurance as payment.

This makes holding insurance companies accountable to their policies and contracts in terms of reimbursement for those needing help with eating disorders very critical.

This makes holding insurance companies accountable to their policies and contracts in terms of reimbursement for those needing help with eating disorders very critical.

Now, while studies show that early diagnosis and evidence-based medical care approach are both critical for recovery, insurance regulations and guidelines in most cases make it almost impossible to receive the appropriate care needed. 

So, if you or your loved one is faced with this type of condition, where do you start? Sadly, these challenges sometimes include determining how to analyze your insurance plans to understand the treatment coverage that is ideal for you. Here are some aspects that you should know about insurance billing for disorders:

What type of eating disorders are covered by your insurance? Billing for eating disorders varies by insurance carrier.

Many insurance policies have these disorders covered by benefits that technically are dictated by the DSM-5 eating disorder list these eating disorder diagnoses:

  • Binge eating disorder
  • Anorexia nervosa
  • Bulimia Nervosa
  • Avoidant/ restrictive intake disorder
  • EDNOS Splits Up
  • ARFID

What will be deducted and what will be go to the out of pocket max for my insurance, and how much is it?

In most cases, once we make a phone call to the insurance company that we know will make billing for eating disorders as about as tough as any art possible, the admission department or the respective department will check the benefits. After the confirmation, we will be informed of any deductible that is supposed to pay out of pocket. This is usually the amount that is supposed to pay before an insurance company covers a claim. The specific amount sometimes varies depending on the insurance company as well as the plan.

how to do billing for eating disorder treatment

For instance, if a deductible is $ 500 and treatment is billed at $ 250 daily, the patient would be responsible for covering the initial two days on their own. After payments are made or the patient meets their deductible, the insurance firm will cover the expenses 100%. Some insurances or actual treatment programs require policyholders to pay co-insurance. This is where the patient is responsible for paying a certain percentage of the entire insurance billing for eating disorders. This can range from 10 to 50%.

What level of care is paid for?

In most cases, the level of care that insurance companies approve for is individual outpatient therapy. The most common process for insurance in terms of level of care, however, of behavioral healthcare is inpatient, then residential care, PHP (Partial Hospital program (PHP), and finally the IOP (intensive outpatient program).  Note that, for anyone to access any of the above treatments, they must:

  • Have benefits under their plan for these levels of healthcare and have out of network coverage is the program is not credentialed as an in-network provider.
  • Meet the necessity, which is evaluated by the severity of symptoms, current weight, vital signs, and blood work results.

How long will the coverage last?

This will depend on various factors. Has the condition improved? Is it deteriorating? Most insurances state in their “insurance billing for eating disorders” policy that according to the ACA almost all have unlimited days, depending on medical necessity. Once medical necessity stops meeting the level of care required for a certain program, insurance  will most certainly require a step down for a less intensive level of care.

For instance, a patient can be admitted into a residential program once stabilized and no longer in need of critical care or is not meeting the clinical or medical criteria. Similarly, if you do not improve in that care, and your condition is worsening, you will be admitted to a better level of care, such as inpatient.

What if insurance does not cover eating disorders?

There are a few things you can do depending on the personal and financial circumstances:

  • Switch plans; This should be pretty straightforward for anybody whose current plan does not cover eating disorders. Not all insurance companies offer this, but some reliable ones do it as a reprieve for members from a high-cost treatment.
  • Some non-profit organizations now partner with various treatment centers to provide financial help to those who cannot afford life-saving treatments. Look for one and ask for help.

It is important to understand these factors so that you can advocate to receive the right treatment. You are capable and strong enough to mastermind your future.

Please text us at 541-ASK-AXIS with any questions!

Here’s what the Supreme Court’s ACA Ruling Means for Addiction Treatment Centers

information on insurance billing for mental health and addiction

On 17th June 2021, the Supreme Court ruled in favor of the Affordable Care Act (ACA), dismissing the challenge that the ACA is unconstitutional.

Since it was signed into law, the ACA, widely known as the health reform law or Obamacare, has allowed nearly 31 million Americans to access healthcare coverage.

Besides banning insurers from basing health coverage on people’s pre-existing conditions, the law prohibited insurance providers from imposing lifetime or annual caps on benefits while also placing limits on yearly out-of-pocket spending.

One of the greatly felt impacts brought about by Obamacare is the comprehensive healthcare plans, which allows people with mental health conditions and substance abuse disorders to access healthcare coverage just like other people.

Over the last four years, some changes have been made to the health care reform law, but the new administration is now reversing some of them.

To help you understand the impact that the Supreme Court ruling has on addiction treatment centers, I’ve covered everything from ACA’s impact on substance abuse to billing and reimbursement requirements for addiction treatment centers.

Supreme Court Ruling on ACA.

Knowing that their policies will cover the need for this higher level of care and future care is critical for all who need mental health services. Taking away any stigma with any mental health disease is important knowing that some if not all of the cost can be shared by the insurance policy they pay for monthly.

As well as knowing the fact the SCOTUS has upheld Obamacare time and time again shows how important the issue is and will be going into the future for more families and individuals who suffer from the mental health dilema day in and day out

Additionally, we shall see the potential impact this ruling has on the demand for treatment of behavioral health conditions and whether or not it will influence reimbursement rates for behavioral health.

This is the 3rd and 4th attempt to strike down the law which provides coverage for this dire need of insurance coverage for many of the millions of Americans who are stricken with mental health issues.

As time goes on the insurance industry will adapt and find a usual and customary reimbursement rate for providers and insurance policy holders alike but know that this mandated coverage has been deemed worthy and constitutional by the supreme court of law.

Earlier Changes Made to ACA

Since its implementation in March 2010, The Affordable Care Act had survived two earlier Supreme Court challenges. However, the law has also seen several changes during the last administration. Below is an overview of some of the biggest amendments made.

Elimination of the Individual Mandate

When ACA was passed into law, all US residents were required to have health insurance or pay a given penalty. This mandate was designed to have everyone, including the more healthy people to enter the health insurance market. Similarly, it helped keep the ACA premium policies low. A 2017 tax overhaul legislation reduced the penalty for not having a health plan to $0. In December 2018, following the tax overhaul, a Texas federal judge ruled that the $ 0 penalty, by law, is no longer a tax, but a command, hence declaring the whole ACA unconstitutional. The case then moved to Supreme Court, and a ruling was made in favor of the ACA on 17th June 2021.

Work Requirements Added to Medicaid

After the ACA Medicaid expansion was adopted, the federal government required states to have Medicaid beneficiaries prove that they either go to school or work. This change was highly politicized, and hundreds of thousands of Americans, including those with substance abuse disorders, were expected to lose their healthcare coverage.

The Ending of Cost-Sharing Reduction Subsidies to Insurance Providers

In 2017, the federal government stopped paying subsidies to insurers, which was seen as a critical element in motivating these companies to keep premiums down. This change disproportionately affected individuals and families who are not eligible for subsidies.

Expansion of Short-Term Plans

Under the initial ACA, short-term insurance that didn’t provide essential benefits was limited to not more than three months. However, in 2019, the federal government extended this duration to 364 days with the option to renew for three years. Since these health care plans are non-comprehensive, they do not fully protect individuals in severe health conditions.

Slashed Budgets for HealthCare.gov Sign-Ups

Initially, the ACA had navigator programs with allocated budgets to help drive the healthcare sign-up campaigns. In 2017, these budgets were slashed, and the net impact was slowed and depressed enrollment. In the following year, the uninsured rates for US residents rose to 8.5% or 27.5 million people (the highest since the ACA went into effect) not having any healthcare plan at any point in 2018. This translated to more people, including those with pre-existing conditions not accessing medical care.

The Impact That ACA Has on Substance Abuse Treatment

The Affordable Care Act made it possible for people with pre-existing conditions such as drug and alcohol addiction to be accepted by insurance providers. At the same time, the 2008 Mental Health Parity and Addiction Equity Act (MHPAEA) mandated all insurers to offer the same level of coverage for substance abuse and mental health treatment as for regular medical care.

Now that the Supreme Court has spared ACA, patients receiving alcohol and drug recovery treatments have been relieved of the stress of covering all the rehab costs. Moving forward, rehab patients will continue to benefit from the covered rehab expenses. That said, here are the four ways ACA will continue to keep inpatient and outpatient rehab treatment costs affordable.

  • Drug and Alcohol Addiction Treatment Remains a Priority: The ACA considers substance abuse disorders as one of the ten elements of essential health benefits. That means Medicaid and other forms of healthcare coverage sold via Health insurance Exchanges should cover services for substance abuse. 
  • Greater Access to Healthcare: More people will continue to sign up and access medical coverage through the expansion of Medicaid and other low-cost insurance plans. Similarly, states accepting federal aid allocated by the ACA will expand Medicaid coverage to individuals and families living below and slightly above the pre-determined federal poverty line.
  • Young Adults Will Remain on Parent’s Health Plan: Individuals up to the age of 26 will continue to receive coverage under their parent’s health insurance coverage. According to a SAMHSA survey, nearly 7% of young adults in the US between 18 and 25 have a substance disorder. By extrapolation, more young adults will continue to benefit from covered rehab expenses under the ACA.
  • Free Screenings and Referrals: If the ACA were ruled unconstitutional, patients with Medicare, Medicaid, or plans under the Health Insurance Marketplaces would have been charged for mental health and alcohol screenings. Now that the law is intact, these services come with no cost for insured individuals.

Billing and Reimbursement for Behavioral Health Service Providers

Now that you know everything about the Affordable Care Act, from the changes made to what to expect moving forward, let’s look at the other side of the ACA – i.e., what it takes for behavioral health service providers to be reimbursed by insurance companies.

Typically, there are four service categories that insurers may consider for reimbursements. These include:

Hospital-Based and Residential Inpatient Care

Hospital-based care and residential programs, widely known as RTC, are acute and sub-acute recovery centers offering nursing care, medical monitoring, and behavioral-health services 24/7. Services provided by these programs are reimbursed on a standardized per-diem basis. Here, the per-diem rate includes all services offered in the program from the accommodation, lab fee, therapies, services of licensed professionals and counselors, dietitians, psychiatric nurses, etc.

Partial Hospital Programs (PHP)

Here, services are offered in an ambulatory setting and require a minimum of 20 hours per week. Billing is done per diem basis, and reimbursement is made on the lesser charges, including services from social workers, addiction counselors, occupational therapists, addiction counselors, etc.

Intensive Outpatient Programs (IOP)

These programs provide patients with behavioral health services for 9 to 19 hours per week for adults and at least 6 hours for children and adolescents. Billing for IOP is cumbersome compared to hospital-based and inpatient programs; hence, it’s challenging to get reimbursement.

Services offered by IOP include family, group, and individual psychotherapy, medical monitoring, and psycho-education. To be eligible for reimbursement, IOP providers must:

  • Supervise the patient at all times.
  • Adhere and be consistent with the initial treatment plan
  • Address the diagnosis that required admission.
  • Provide enough IOP care to patients for about 12 to 16 weeks.
  • Be consistent with clinical best practices.

Other Key Takeaways

Due to the Supreme Court ruling, enrollment for healthcare plans will probably rise, and more people with substance abuse disorders will be seeking specialized treatments. It’s therefore fair to conclude that to a given extent, the demand for treatment services for behavioral health conditions will increase.

As far as reimbursement is concerned, the current rates are significantly lower than those for other medical and surgical treatments, and this has led to a lower network of behavioral health providers participating in healthcare plans. If this were to be resolved, health plans would need to raise reimbursement rates. But even then, it would be very costly to try and level up with what behavioral health providers charge patients who pay out-of-pocket. And while there are no official plans to raise reimbursements yet, efforts to boost these rates will be highly beneficial.

Last but not least, addiction treatment centers that accept Obamacare, Medicare, and Medicaid plans should prepare to help more patients access quality care. They should also keep up with the CMS billing requirements to ensure compliance and minimize delays of reimbursements which could otherwise hurt service delivery.

Most healthcare facilities treat eating disorders through comprehensive therapeutic programs with an emphasis on continuity of care. PHP and IOP billing for eating disorders can be complicated.

Day treatment programs commonly known as PHPs and IOPs are a popular option because they allow the patient to get sufficient mental and emotional support from a multidisciplinary team of professionals. IOP often involves several hours of treatment, including nutritional counseling, meal support, therapy, and medical supervision.

PHP and IOP Billing pro tips

PHP is another option and is used on patients who do not qualify for inpatient hospitalization but are stable enough to benefit from outpatient treatment. PHP for eating disorders includes weekly sessions with psychiatrists, individual therapy sessions, medical monitoring, nutritional support and planning, guidance on cognitive coping skills and group or family therapy. Insurance billing for eating disorders differs with the type of care.

Insurance Billing for Eating Disorders For PHP

Partial Hospital Programs (PHP) are provided to patients who do not need hospitalization and require the patient to have at least 20 hours of care per week. Some PHP services are provided in ambulatory settings.

PHP billing information

All PHP bills submitted by hospitals should be under one of the four Type of Bill (TOB). Outpatient hospitals, Critical Access Hospitals (CAH), and Community Mental Health Centers (CMHC) have respective codes.

Outpatient can be considered both PHP and IOP

131: admit through discharge

132: interim-first

133: interim-continuing

134: interim-last

CAH

851: admit through discharge

852: interim-first

853: interim-continuing

854: interim-last

CMHC

761: admit through discharge

762: interim-first

763: interim-continuing

764: interim-last

The appropriate healthcare common procedure coding system (HCPCS) code for eating disorders is 90791 or 90792.

Sequential Billing

 Payers require providers to submit PHP claims for continuing treatment in sequence.

  • If the patient completes the treatment in one month, providers should submit bills through TOB codes 131, 851, or 761.
  • If the treatment takes more than one month, the provider should submit claims using TOB codes 132, 852 or 762.
  • If the treatment takes more than two months, the provider should use TOB codes 133, 853 or 763.
  • Providers should use the codes for continuing claims until the last month when they should use TOB 134, 854 or 764.

Tips on PHP and IOP BillingInsurance Billing for PHP and IOP Eating Disorders 

Intensive Outpatient Programs (IOP) is a form of care where adult patients are treated for 9 to 19 hours per week and a minimum of six hours for children. S9480/0905 are the per diem IOP codes for behavioral problems, including eating disorders. This billing code is only used for private payers because Medicare does not recognize it. Further, the following codes can be used if the payer insists:

H2019: therapeutic behavioral services, per 15 minutes

H2020: therapeutic behavioral services per diem

Most payers require pre-authorization for IOP services to qualify for reimbursement. Patients must undergo a minimum o 180 minutes of active therapy to reimburse the provider at the per diem rates. This is why it is very important for providers to have clinical documentation of the full 180-minute session when making IOP bills. Healthcare providers are required to obtain concurrent authorization if they wish to continue treating the patient.

Payers require providers to use the UB-04 claim form specifying the preferred Type of Bill (TOB) and Revenue Codes (RC). The applicable code for eating disorders in TOB 131, RC 0905 and HCPCS code S9480. For Medicaid patients, the provider has to indicate the level of care using a modifier.

Some payers allow independent practitioners to provide IOP services and submit bills using the H2035, which is reimbursed using hourly rates instead of facility rates.

Avoid Duplicate Billing

Healthcare providers should only bill for one type of IOP or PHP service per day even if two or more units or specialists are managing the patient. Submitting duplicate claims often results in denied or delayed reimbursements.

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. 

Billing for IOP in a nutshell

Are you seeing changes in IOP billing for mental health in 2021? We certainly are. There are new requirements coming from UHC, BCBS, Cigna, Aetna and all the rest for all levels of care including RTC and PHP billing all the way through outpatient services.

When dealing with IOP billing specifically, there are generally a few more requirements and consistent attention needed to make sure everyone involved is happy. From the patient being able to continue their treatment, to the doctors treating the patient, and of course, making sure the insurance companies are on board with allowing the overall treatment to happen.

Behavioral health levels of care

Behavioral health facilities essentially provide four types of services that insurance companies may consider reimbursement when treating a patient.

  1. Hospital-based inpatient programs, that require medical monitoring, nursing care, and other behavioral health services treated 24/7.
  2. Residential treatment programs, also known as RTC, which is more of a sub-acute facility based monitoring, offering other behavioral health services.
  3. Partial hospital programs, better known as PHP, providing services in an ambulatory setting, and generally requires 20 hours per week.
  4. Intensive outpatient programs, known as IOP, where the patient is provided with behavioral health services for at least 9 to 19 hours a week for adults, and for children and adolescents at least six hours is generally acceptable.

There are so many different modalities and service types when billing for IOP, compared to inpatient and hospital-based programs, which in turn makes it more challenging when trying to get reimbursement.

Similar Article: The Secret To Getting Reimbursed Quicker- Claims Follow Up

Typical services covered in IOPs

If a facility is offering IOP services, they must be licensed at the state level and usually will treat substance abuse and most mental health disorders. Most facilities will set up a weekly schedule for IOP patients, consisting of meeting at least two hours per day, and from three to five days a week.

Typical services generally covered are:

  • Individual psychotherapy
  • Family psychotherapy
  • Group psychotherapy
  • Psycho-educational services
  • Medical monitoring

CMS guidelines required in order for the facility to be eligible for reimbursement for IOP services are:

HCPCS and revenue codes for IOPs

IOP billing codes may differ depending on what the patient’s diagnosis is, and what services are provided primarily either for substance abuse or for mental health issues. Also, another thing to remember when billing for IOP services, if the patient has a dual-diagnosis for both substance abuse and mental health, you can generally only bill for one IOP session per day, even if both were being addressed in therapy. It is always good to document that information for the insurance company, but beware to not submit duplicate claims, as they’ll inevitably get denied and or delay payment.

  • S9480/0905: The per diem outpatient IOP code for psychiatric issues which may include eating disorders, is S9480, and most times is always paired with revenue code 0905. This is generally used for private payers, as Medicare does not recognize these codes.
  • H0015/0906: The per diem outpatient IOP code for all chemical dependency is H0015, and is always paired with revenue code 0906.

Similar Article: 5 Insurance Billing Errors Drug Treatment Centers Can Avoid

Pre-authorization, clinical and IOP all go hand in hand

Just like with all inpatient level care services, most insurance companies require all IOP services obtain a pre-authorization before reimbursement is complete. Although IOP, technically provides only two to three hours per day, most payers require at least 180 minutes of active therapy per day in order to reimburse the per diem rates.

This is why I stated earlier, that clinical documentation is a key element in supporting the full 180 minutes per day, otherwise you’ll end up with a denied claim. A concurrent authorization is generally required to continue to treat the patient and sometimes referred to as short-term interventions, where all clinical and progress of the patient is considered and decided for continued authorization.

We hope this was a helpful and informative article about IOP in particular. If you have any questions about IOP billing and how to maximize your reimbursement for behavioral health services or any other billing concern, please feel free to contact us via email, or check out a ton of extra billing resources here.

On June 6th, 2019, Anthem, Inc. announced that they are in the definitive stages to acquire Beacon Health Options, Beacon currently serves more than 36 million individuals across all 50 states, and 3 million of those under comprehensive risk-based behavioral programs.

“Our member-focused, integrated clinical care model helps individuals and their families cope with their physical and behavioral health challenges. Together, we will expand access and enhance the quality of care for our mutual members. I am proud of the talented and committed team at Beacon, and we look forward to our future with Anthem.”Russell C.Petrella, Ph.D., Beacon Health Options President and CEO

Anthem didn’t disclose a price it is paying Bain Capital Private Equity and Diamond Castle Holdings for Beacon Health, which is privately held. The acquisition is expected to close in the fourth quarter of 2019. However, this is a great opportunity for Anthem to utilizing Beacon Health Options, already stellar business model, not to forget they are the country’s largest independently held behavioral health provider.

“As Anthem works to improve lives, simplify healthcare and serve as an innovative and valuable partner, we’re focused on providing solutions that address the needs of the whole person,” -Gail K. Boudreaux, President and CEO, Anthem

The acquisition will offer the opportunity to combine both successful business models to diversify the health services and deliver market-leading integrated solutions. Progressing towards a stronger portfolio of specialized services, improved clinical expertise, and ability to offer broader provider networks and establishing positive relationships.

“We are excited to partner with Anthem to serve the behavioral health needs of more than 60 million Americans,” –Russell C. Petrella, Ph.D., Beacon Health Options President and CEO

Once the acquisition is complete Beacon, combined with Anthem’s behavioral health business, will operate as an integrated team within Anthem’s Diversified Business Group. Russell C. Petrella, Ph.D., Beacon Health Options President and CEO, as well as other key members of Beacon’s senior team, will join Anthem’s Diversified Business Group to lead the efforts to offer innovative behavioral health solutions and further expand this business.

“With an extensive track record in behavioral health, Beacon fits well with our strategy to better manage the needs of populations with chronic and complex conditions, and deliver integrated whole health solutions. Together with Beacon, we will enhance our capabilities to serve state partners, health plans and employer groups as they seek to address consumer behavioral health needs.” -Gail K. Boudreaux, President and CEO, Anthem

We are excited and believe this is very significant as more insurers are working on addressing the determinants of care for mental illness that fall outside of the traditional medical care. One out of every five adults suffers from mental illness, and is only increasing, according to the National Institute of Mental Health.

What are your thoughts on this acquisition? Is this good or bad, why so?

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.

When you think of insurance billing, you probably think of some nice sweet receptionist type person in your doctor’s office taking your insurance card before your appointment and charging your co-pay. Technically, this is a type of insurance billing – just not what I am talking about in this blog. There are huge differences when you think medical billing vs. behavioral health billing.

Behavioral health billing compared to medical billing is very different in the fact that medical professionals (like your primary care physician) bill for specific treatments such as:

  • Office visit
  • lab test
  • X-rays
  • MRI

This billing is pretty simplified and streamlined. However, with mental health/substance abuse facilities, they may bill for therapy, psychological testing along with medical management for the patient – most of the time in “bundled” services and codes for levels of care such as RTC, PHP, and IOP.

What does that include and mean for the patient and mental health professionals? I’ll tell you.

The insurers may have certain regulations and guidelines like:

  • limiting how long therapy sessions will be,
  • how many days they’ll pay for,
  • and may even have a maximum on treatments they’ll even pay for in all.

This, in turn, makes it difficult for mental health professionals to come up with a master plan to treat the patient and also make sure they get reimbursed for services rendered.

Another thing is, It is important for behavioral health providers to know that many insurance carriers and state Medicaid programs will outsource their mental health claims to a third party. This means they use a contracted company to process, manage, and pay claims.

It is important for an inpatient mental health or addiction program to be aware of this when submitting claims. If this is missed, your claims can be sent to the wrong place — and will just be denied and then obviously not paid in a timely manner.

All you have to do is ask who processes the claims when you call provider services. You can do this when you are actually checking benefits for a patient or anytime before you actually submit claims.

This process of billing for behavioral health can get very complicated. One reason is that even when you are calling into the insurance companies (instead of using a web portal), either the customer service representative is not fully trained, or they are unable to give you the correct information and you wind up being transferred to several different departments and representatives. Furthermore, a lot of these call centers are overseas and the connection is not always the best – making the conversation very difficult to understand. Often times there is this weird volume issue where it sounds like the rep is whispering. One way to overcome these issues is to ask for an “onshore representative” or even request speaking with a supervisor to get an honest and helpful customer service experience.

I’ve found many times, some representatives will try and distract from giving you the right information to move forward in the claims process, and keep you in limbo or going in circles. It is almost like perhaps they are trained to do so in order to slow the payment for the claim.

I really don’t know exactly what the issue is when these situations arise, but I do have some ways to get through those walls of confusion. It gets frustrating and always is a good idea to have someone on your side that knows how and what to do in those situations.

As simple as it sounds, always and I repeat..ALWAYS getting a reference number and name of the representatives you speak with, is one of the smartest pieces of information you can get for each and every interaction when calling on claims. Documentation..rules the nation is what I say!

Imagine being on the phone for over hours just for one difficult claim, and you finally speak to someone who makes sense, and you hang up thinking everything ok, just to find out a couple days later that nothing was done, and they have no record of what was discussed. Talk about heartbreaking. So do yourself and everyone else a favor, and just make sure to get that all so important reference number. Trust me, you’ll thank yourself later.

Heaven forbid you’ll have to go through the “Claims Chamber Torture”, and all goes well, it should only take at least 30 days from the when they first receive the claim. In some cases, they can move faster with a quicker turnaround time if everything goes smoothly. But as a general rule, you can expect it to be around 30 days.

For most in-network mental health facilities, they are contracted with insurance companies and cannot bill their patients for any balance after reimbursement is done. This is what is called “balance billing”. They have to accept that rate given and write off the remaining balance. As far as out of network facilities, you can accept the reimbursement and bill the patient whatever balance may be outstanding.

There are so many factors that must be accounted for when billing for mental health services. If you are running into issue after issue when attempting to get reimbursement, you aren’t alone.

There are a number of third-party insurance billing companies who are experts at this and don’t cost you all that much. If you haven’t considered outsourcing your insurance billing processes, maybe it’s time to do so now. With the many options of outsourcing for mental health billing, it is very important to team up with a company that knows what and how things are done when billing.

Reaching out to an outsourcing company and getting an assessment is the first step in building a strong relationship with your practice. In the long run, you’ll find yourself giving all of your focus on your patients where it really matters.