Category: Health Insurance

Get Quicker Access to Payments from UHC/OPTUM… Is this true?

Is this true from UHC?

To speed up payments to your practice, UnitedHealthcare is phasing out paper checks and moving to digital transactions, where not prohibited by law.

You’ll need to choose between two options for receiving payment from UnitedHealthcare – ACH/direct deposit or virtual card payments. Both of these are facilitated by Optum Pay on behalf of UnitedHealthcare.

If your practice/health care organization is already enrolled and receiving claim payments through ACH/direct deposit, there is no action you need to take.

The California Medical Association (CMA) has learned that UnitedHealthcare (UHC direct pay issue) is in the process of discontinuing physician payments via paper checks and will instead require both contracted and non-contracted physicians to receive payment via automated clearinghouse (ACH)/direct deposit or through virtual credit card payments.

The change, first communicated in UHC’s March 2020 Network Bulletin, was originally planned to be rolled out in phases beginning in mid-2020. Due to the COVID-19 pandemic, the rollout of the program was delayed.

UHC has since announced in its August 2020 Network Bulletin that the program will move forward with a phased rollout beginning with its commercial line of business starting in August 2020.  UHC Medicare Advantage and Community and State (Medicaid) Plans will follow with rollouts slated for fall 2020 and early 2021.  

UHC will be publicizing the change to both contracted and noncontracted physicians, who will be directed to sign up for ACH/direct deposit through Optum Pay or via the website. Physicians who do not elect to sign up for ACH/direct deposit will automatically be signed up to receive virtual credit card payments in place of paper checks. 

Physicians with questions or concerns, or that need to request a hardship exemption from this policy, should contact their UHC Provider Service Advocate or UHC at (877) 842-3210 for more information.

What is a virtual credit card?

With the virtual credit card (VCC) payment method, payors send credit card payment information and instructions to physicians, who process the payments using standard credit card technology.

This method is beneficial to payors, but costly for physicians. Health plans often receive cash-back incentives from credit card companies for VCC transactions. Meanwhile, VCC payments are subject to transaction and interchange fees, which are borne by the physician practice and can run as high as 5%per transaction for physician practices. Physicians can avoid these interchange fees by enrolling in ACH/direct deposit.

What to do on the UHC direct pay issue?

This all depends on the business set up and values of your institution. This can cause major problems for some programs and be slightly beneficial to others. Below is an exert from the specialty benefits form for UHC:

“I authorize UnitedHealthcare Specialty Benefits to direct the net amount of my benefit payment to be deposited directly by electronic funds transfer and credited to my account as indicated at the financial institution designated below. If any payments made are dated after the date of my death, I hereby authorize and direct the said financial institution on my behalf and on behalf of my executors or administrators to refund any such payments to UnitedHealthcare Specialty Benefits and to charge the same to my account.”

The form does not have all the disclaimers that could possibly affect your group/facility or your providers.

Claims Department
Direct Deposit Agreement
For Payment of Benefit to Financial Institution

Here is what UHC says the benefits are for ACH

Automated Clearing House (ACH) /direct deposit

  • We recommend ACH because it’s the quickest form of payment available and there are no fees for the service. 
  • Payments can be routed by both the tax ID number (TIN) and National Provider Identifier (NPI) number level.
  • Enrollment generally takes less than 10 minutes. You will need to provide your current bank account information.
  • Funds are deposited directly in to your bank account – there are no paper checks or remittance information to lose or misplace.

Here is what UHC says the benefits are for Virtual Card Payment (VCP)

  • If you don’t enroll in ACH, in most instances you’ll receive a virtual card payment from Optum Pay. VCPs are electronic payments that use credit card technology to process claim payments. There is no requirement to share bank account information.
  • A 16‐digit, single-use virtual card will be issuedopen_in_new for payment (single or multiple claims). You’ll receive a VCP in the mail; for quicker access, you can view the VCP statement in Document Library.
  • Each VCP is issued for the full amount of the claim payment. However, VCPs are subject to additional terms and conditions, including fees, between you and your card service processor.
  • You can enroll in ACH even after receiving a VCP. However, ACH will only apply to future payments and can’t be applied to previous payments.

We can help navigate if this is something that would benefit any behavioral health institution

Find out how insurance billing works for RTC, PHP, IOP substance abuse and mental health.

Insurance Billing 101

What is a clearinghouse?

A clearinghouse is connected to various insurance companies.  Our software sends claims to the clearinghouse where they are basically checked (scrubbed).  If the claim passes the scrub it is then forwarded to the insurance company or another clearinghouse if our clearinghouse is not connected to the insurance company.  (this has to do with security) The insurance company will do 1 of 2 options accept or reject.  If accepted the claim will process and return to the clearinghouse with an ERA which will come back to Practice Suite.  There are a few exceptions to ERA’s coming back the biggest one BCBS you will probably not see an ERA from them.

The clearinghouse we use with Practice Suite  is RelayHealth.  They have been bought by Emdeon and they are now known as Change Healthcare.  Relay uses a 4 digit CPID NOT a 5 digit payer ID. Even though they are Change they still use the existing Relay structure.

We also use Office Ally and Availity.

Availity is BCBS preferred clearinghouse.

What is a payer ID? CPID (Claim Payer IDentification)?

A payer ID is a routing number, or address. Tells the clearinghouse where to send the claim like a bank sends a check. Emdeon uses 5 digit Payer Id the most common. This is the # that most insurances will give as their payor id. RelayHealth made their own CPID for their system. This is a 4 digit number. 

So basically if you put in a 5 digit payer ID in the insurance set up instead of the 4 digit CPID the claim will not go anywhere.  It is like trying to cash a check from a bank at a credit union.  

Relay has two types of  CPID’s for Institutional claims (UB04) and different CPID’s for professional claims HCFA/CMS 1500.  Relay has a conversion search engine within their portal to translate payor id to CPID.

What is a UB04?

This is an institutional claim form. (used for facilities our most common claim right now)

The UB-04 form is a form that any institutional provider can use for the billing of medical and  mental health claims. The UB-04 uniform billing form is on white standard paper with red ink, which is used by institutional providers for claim billing.

What is a HCFA 1500 (hick fa)? CMS 1500?

This is a professional claim (used for providers, for Florida’s weirdness and UHC IOP and ROP claims).

What is the Healthcare Financing Administration (HCFA) form in Medical Billing

… The HCFA is paper form, also known as the CMS-1500 form, and the Professional Paper Claim Form, is used for reimbursement from various government insurance plans including Medicare, Medicaid and Tricare.

What is an ERA?

This is an Electronic Remittance Advice. Also known as a Remit or Remittance. It is the electronic form of the Explanation of Benefits (EOB) this tells us how the claim processed.

What is a Revenue Code?

 The revenue code tells an insurance company where the procedure was performed.

What is a HCPCS / CPT Code (Hick Picks)?

The Healthcare Common Procedure Coding System (HCPCS, often pronounced by its acronym as “hick picks”) is a set of health care procedure codes based on the American Medical Association’s Current Procedural Terminology (CPT).

What is the difference between HCPCS and CPT?

HCPCS has its own coding guidelines and works hand in hand with CPT. HCPCS includes three separate levels of codes: Level I codes consist of the AMA’s CPT codes and is numeric. Level II codes are the HCPCS alphanumeric code set and primarily include non-physician products, supplies, and procedures not included in CPT.

What is a Type of Bill?

This four-digit alphanumeric code provides three specific pieces of information after a leading zero. CMS ignores the leading zero. This three-digit alphanumeric code gives three specific pieces of information.

  • First Digit = Leading zero. Ignored by CMS
  • Second Digit = Type of facility
  • Third Digit = Type of care
  • Fourth Digit = Sequence of this bill in this episode of care. Referred to as a “frequency” code

What does ICD 10 CM stand for?

The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD10CM) is a system used by physicians and other healthcare providers to classify and code all diagnoses, symptoms and procedures recorded in conjunction with hospital care in the United States.

What is a Revenue Code? Revenue codes tell insurance companies the type of services patients received, the types of supplies used and the department in which services were rendered. For example, a charge for an emergency room visit for urgent care would carry revenue code 0456.

What is ROI?

Release of information (ROI) in healthcare is critical to the quality of the continuity of care provided to the patient. It also plays an important role in billing, reporting, research, and other functions. Many laws and regulations govern how, when, what, and to whom protected health information is released.

How long is an authorization to release information good for?

an expiration date or an expiration event that relates to the individual or the purpose of the use or disclosure. HIPAA does not impose any specific time limit on authorizations. For example, an authorization could state that it is good for 30 days, 90 days or even for 2 years.

What is HIPAA?

HIPAA (Health Insurance Portability and Accountability Act of 1996) is United States legislation that provides data privacy and security provisions for safeguarding medical information.

What kind of personally identifiable health information is protected by HIPAA Privacy Rule?

The Privacy Rule protects all “individually identifiable health information” held or transmitted by a covered entity or its business associate, in any form or media, whether electronic, paper, or oral. The Privacy Rule calls this information “protected health information (PHI).”

What is considered personal health information?

Protected health information (PHI), also referred to as personal health information, generally refers to demographic information, medical histories, test and laboratory results, mental health conditions, insurance information, and other data that a healthcare professional collects to identify an individual and ..

What is the difference between PII and PHI?

HIPAA uses the term Protected Health Information (PHI) to refer to protected data, but the concept is very similar to the term Personally Identifiable Information (PII), which is used in other compliance regimes. … PHI includes anything used in a medical context that can identify patients, such as: Name.

What penalties can occur by violating HIPAA?

What is the penalty for a HIPAA violation? HIPAA violations are expensive. The penalties for noncompliance are based on the level of negligence and can range from $100 to $50,000 per violation (or per record), with a maximum penalty of $1.5 million per year for violations of an identical provision.

Can you go to jail for HIPAA violation?

Like the HIPAA civil penalties, there are different levels of severity for criminal violations. The minimum penalty is $50,000 and up to one year in jail. Violations committed under false pretenses require a penalty of $100,000 and up to five years in prison.

How can HIPAA violations be prevented?

7 Ways Employees Can Help Prevent HIPAA Violations

  1. Be educated and continually informed. …
  2. Maintain possession of mobile devices. …
  3. Enable encryptions and firewalls. …
  4. Double check that files are correctly stored. …
  5. Properly dispose of paper files. …
  6. Keep anything with patient information out of the public’s eye. …
  7. Use social media wisely.

Definition of demographics: Specific demographic factors which identify and distinguish.

We use several types of demographics:

  1. Facility 
  2. Clinical / Medical Director
  3. Patient
  4. Policy holder (can be same as patient)
  5. Insurance company

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

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 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


851: admit through discharge

852: interim-first

853: interim-continuing

854: interim-last


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?