Category: Health Insurance

Health insurance carriers have rarely provided coverage for families that chose a wilderness program to help their child.

With higher levels of therapeutic intervention, processes, safety, and now accreditation, the debate about whether insurance should cover outdoor behavioral programming is heating up.

Struggling with either addiction or mental health issues is no matter to be taken lightly for anyone, especially those still in developmental stages. It is widely agreed upon that it takes multiple models and multiple “tries” in order to have a successful outcome after treatment – and this includes wilderness programs.

Wilderness therapy programs can act as a huge resource for those that need it, however they can also use up 30 to 45 days of benefits – even without being billed to the insurance carrier.

Why is 30 to 45 days a big deal?

Because a lot of families have behavioral health benefits with a set number of days allowable for treatment purposes. This means that although these benefits are not being used – the child can be viewed as still “in treatment” or receiving care towards an overall expected recovery time.

Authorization for additional days receiving residential or partial hospitalization treatment will not be approved in such cases.

Wilderness programs and insurance carriers have never really been on the same page – this is just one of many examples showcasing this disconnect.

Does insurance cover wilderness therapy programs?

This seems like a no-brainer right? Any behavioral health or therapeutic program should be covered under the Affordable Care Act’s ten essential health benefits.

Well, it’s not that black and white.

When it comes right down to it, it can be difficult to get insurance carriers to reimburse RTC, PHP, or IOP for wilderness type programs. At the very least, with the help from billing professionals or a seasoned in-house biller, it is possible to get reimbursement for individual, group, and family therapy given by licensed clinical professionals up to about $300 or so per week.

There is progress being made though, things are changing with wilderness care – the Outdoor Behavioral Health Council and variety of national institutions are now accrediting these programs.

Much like residential and outpatient drug rehabs and mental health programs, a set of operations and processes can now be followed in order to standardize treatment. More and more regulation is coming to the once “troubled” outdoor behavioral therapy world. And that is a good thing for the kids attending, the staff, payors, and the programs themselves.

So much progress has been made that a code specific to wilderness therapy has been developed for billing.

It has already been put in place and gives all programs and third party billers a new tool to advocate for proper reimbursement (as with everything in behavioral health – there are no guarantees).

Maybe it is time for insurance companies to start listening to their members – to the needs of their members.

Many families have teens and young adults who need an option a bit less scary than inpatient drug rehab or therapeutic boarding school. A wilderness program can provide a life experience as well as a solution at a potential fraction of the cost of traditional models.

The fight for insurances to cover wilderness.

A new trend is happening – families are starting to sue insurers in order to get wilderness therapy to cover RTC and other higher levels of care. This has only started to happen in 2017 because of how much more safe and effective wilderness programs have become.

Since January, 2016, there have been class actions filed against Cigna, Oxford, Empire Health, and BCBS. Anthem Health out of Kentucky just recently settled a similar suit.

These lawsuits to get insurance to cover wilderness have been filed in Florida, Kentucky, New York, and Utah – mostly stemming from the expansion of the 10 essential benefits to include mental health.

Because insurance carriers determine level of care needed more by the structure of the program and the professional level of the staff than by the physical nature of the buildings, wilderness programs can be set up in a way that they qualify for Partial Hospitalization (PHP), if not Residential Treatment (RTC).

For instance, it is not uncommon for a week in the life of wilderness to include:

4-5 days hiking/learning outdoors skills
Daily academics/reading assignments
Daily group therapy
Weekly family therapy
Weekly visits with a individual psychologist or social worker
On-call medical assistance from a registered nurse or medical doctor (admits get evaluated prior to enrollment in the programs)

The above structure meets all the requirements for many of the major health insurance carriers out there.

Privately paying $500 per day is steep for any sort of treatment.

It is almost unmanageable for any family without the help from your already expensive health insurance. However, this daily rate helps teens and young adults struggling with:

Addiction
Anxiety
Aspergers
Austism
Depression
Eating disorders
Oppositional Defiance Disorder (ODD)
Post Traumatic Stress Disorder (PTSD)
Self Harm
Suicidal thoughts
Traumatic Brain Injuries (TBI)

Because wilderness programs provide such a unique experience and a unique approach to treatment, they can be expensive.

Without help from insurance these programs can be upwards of $20,000 total per stay.

Is residential or transitional treatment needed after wilderness?

Most licensed mental health and substance abuse professionals will tell you that wilderness programs provide an excellent service to the adolescent and even young adult treatment world. They are a great place for a struggling teen to stabilize and to start the path back to a healthy life.

In many cases wilderness is used as a first step in the continuum of care of the overall treatment process – followed by a brief residential stay, then a longer transitional program, and finally on to outpatient and aftercare.

The bottom line is that medical necessity will determine if residential care is needed. Although each insurance carrier has a different definition, here is the basic criteria:

Has there been a failed attempt at a lower level of care in the recent past? Perhaps outpatient has been tried and there have been failed tests. Or perhaps they left a wilderness program before graduating, or left a residential program against medical advice (AMA).
Plain and simple there are zero wilderness programs that are in-network with any provider. If there are no out-of-network benefits or no chance for a single case agreement, then wilderness won’t be an option.
A potential harm to self or others.
Recorded/documented severe change in any variety of daily active functioning – eating, sleeping, socializing, etc.
Constant cycle of inappropriate behavior and negative actions with zero likelihood of change in the existing environment.

Each one of these criteria can be enough to warrant RTC level of care.

RTC level of care does not mean the entire stay is covered, it just means there is an immediate medical need for residential treatment. An average authorization is only 1-14 days (so utilization reviews become very important in continuing coverage).

After each authorization, a utilization review will need to be done with the case manager in order to approve more coverage or determine if a drop in level of care is warranted.

What are the differences in ongoing treatment options after wilderness?

Long-Term Residential Treatment

This is 24 hour a day treatment for at least 3 months in a stand alone facility. These programs are usually set up to allow participants to drop down to a less structured program while they acclimate back into real life.

Generally long-term RTC facilities take a holistic approach and offer a variety of therapeutic models to cater to a large audience. Treatment is not done in a vacuum. What works for one person may not work for another.

Everyday will be completely planned out in advance with a heavy structure and a set number of rules or guidelines to follow.

Short-Term Residential Treatment

It is common for teens or young adults to transition directly to a short term stay in residential care directly after wilderness. These programs are set-up for a quicker 21-45 day stay where stabilization and transition is more of the priority.

Day Treatment with Sober Living (Transitional Treatment)

Transitional treatment programs are a relatively new concept and were started mostly for the young adult world. Residential programs saw a need to slowly move participants back into the real world – often somewhere away from old acquaintances and old triggers.

These programs start after long or short-term residential treatment and can last up to 18 months

Participants attend individual and group therapy throughout the week while living in a sober house or apartment with their peers.

Outpatient Treatment

The final step down in structured treatment with peers – this is the least intense of the programs. This is also the least expensive and should be done after wilderness at the very least in order to avoid relapse and keep participants engaged in their recovery.

Outpatient programs do not always have a set time frame but 16 weeks is the norm. They include further education on addiction and mental health, drug testing, as well as individual and group therapy up to 12 hours a week.

Insurers Have a Legitimate Defense… With an Asterisk

Health care providers do have cause to deny coverage when it comes to outdoor behavioral therapy. Two main points come to mind when putting yourself in the payors shoes:

Take into consideration the cost and benefits of wilderness therapy. Is this one particular program all that is needed for long term recovery?
- What needs to be proven is that it is more likely that this alternative program is going to be the more cost effective than a traditional model or no treatment at all.
There is not a ton of empirically based evidence to suggest this type of treatment works.
- Cigna flat out suggests that wilderness programs are not evidence-based.
- Aetna considers this form of rehab to be at the very most – experimental and investigational. Here is their policy:

Aetna considers alternative medicine interventions medically necessary if they are supported by adequate evidence of safety and effectiveness in the peer-reviewed published medical literature.

* Here is the asterisk: Medical necessity is tricky. It is the embodiment of personalized care. In many ways behavioral health is trailblazing the way to where our Nation’s healthcare is going – Precision Medicine.

Because every individual’s treatment plan must be tailored to them specifically, to their needs and their issues specifically – it becomes difficult to say that all types of behavioral health programs should be covered for everyone with health insurance.

Insurers require preauthorization be done by before any amount of days of treatment will be covered.

A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency.

Preauthorization isn’t a promise your health insurance or plan will cover the cost.

If a kid’s medical history and current physiological issues, personality, or substance use disorders are not going to be significantly helped by spending time in the wilderness (as determined by a mental health professional), then why should a health plan throw blanket coverage over all options?

This is how they work with any condition or disease. Treatments must be vetted – there must be a standard set on how, when, and how often treatment takes place along with other interventions if improvement is not being made.

Just take diabetes as an example. There are a variety of medications and interventions done by both the individual and their treatment team to achieve a successful outcome. This holds true in behavioral health as well.

If you are a family looking at a wilderness program for help – or a program thinking of admitting a family and you are hoping to get some sort of insurance reimbursement, then both sides need to take a close look at medical necessity and if there is an argument for this type of treatment.

There is no inherent negative intent for insurance companies to deny coverage.

They simply must act in the best interests of both their members and their shareholders. Sometimes these lines get blurred – or there is just not enough info out there to make the right decision.

Try to keep an open mind and an adjustable perspective when seeking reimbursement and working with health insurance carriers. The behavioral health world is not a science. It is constantly moving and adapting and we are all trying to catch up as quick as possible.

To Summarize Wilderness Treatment and Insurance Benefits

Wilderness programs, also known as wilderness therapy or outdoor behavioral healthcare programs, are therapeutic interventions that combine outdoor activities and group therapy to address behavioral and emotional challenges in individuals, particularly adolescents and young adults. These programs typically take place in natural settings and involve activities such as hiking, camping, and other outdoor adventures.

When it comes to behavioral health insurance benefits, the coverage and reimbursement for wilderness programs can vary depending on several factors:

Insurance Provider: Different insurance companies have their own policies and guidelines regarding coverage for wilderness programs. Some insurance providers may include wilderness therapy as a covered service, while others may not.

Policy Coverage: The specific insurance policy that an individual has will outline the types of behavioral health services that are covered. It is essential to review the policy documentation or contact the insurance provider directly to determine if wilderness therapy is included.

Medical Necessity: Insurance coverage for wilderness programs often depends on whether the treatment is deemed medically necessary. This determination is typically made by a qualified healthcare professional or mental health provider who evaluates the individual’s condition and recommends the program as part of their treatment plan.

Out-of-Network Coverage: Wilderness programs are almost always considered out-of-network services, meaning they are not directly contracted with the insurance company. In such cases, individuals may have to pay for the program upfront and then seek reimbursement from their insurance provider based on their out-of-network benefits.

Pre-authorization and Documentation: Insurance providers may require pre-authorization for wilderness programs, which means obtaining approval from the insurance company before beginning the treatment. Additionally, proper documentation from healthcare professionals, including diagnoses and treatment plans, may be necessary to support the claim for coverage. This can be done retro-actively as well.

It’s important to note that even if a wilderness program is covered by insurance, there may still be limitations or restrictions, such as a maximum number of days or sessions, co-pays, deductibles, or other out-of-pocket expenses. It’s recommended to thoroughly review the insurance policy and consult with the insurance provider to understand the specific coverage and any associated costs.

Overall, the impact of wilderness programs on behavioral health insurance benefits depends on various factors, including the insurance provider, policy coverage, medical necessity, and the individual’s specific circumstances. It is crucial to gather information directly from the insurance company to determine the extent of coverage and potential reimbursement for wilderness therapy.

The specific number of patients allowed in either a Partial Hospitalization (PHP) or Intensive Outpatient Program (IOP) for behavioral health can vary depending on the state, program, facility, and the resources available.

However, there is no universally fixed limit on the number of patients that can participate in an IOP. Generally, state insurance agencies nor insurance carriers do not have a requirement.

Here is what we will try to answer:

1. How many patients are allowed to be in PHP/IOP together?

2. Is reimbursement higher for per diem or per session?

2. Can S9480 ever be billed on a CMS 1500 without the revenue code or must it always be on UB04?

3. A little clarity on how to bill using the S9480 code…for example if a program had 3 patients in treatment and they met for 3 hours a day 3 days a week. What would that look like in terms of insurance billing?

There are a lot of variables to insurance billing, each policy of a plan needs to be vetted and checked for limitations and criteria

The capacity and census of a PHP/IOP can depend on factors such as the size of the facility, the staffing levels, the treatment philosophy, and the specific needs of the patients. Some PHPs/IOPs may have smaller groups with fewer patients to allow for more individualized attention and a more intimate therapeutic environment. In contrast, others may accommodate larger groups if they have the resources to support it.

Although the reimbursement rate for IOP (S9480) should not be the same as individual, family, group therapy (90837/90847/90853) because it’s per diem and these codes add up to the same clinical hours to be about 3 hours a day, reimbursement is sometimes equal. Many insurance carriers do not allow for multiple services for therapy to be billed on the same day regardless of modifiers that can be used to specify this. Providers must bill for the actual services provided essentially.

S9480 will generally be billed on UB04 since it is a per diem fee although some insurance carriers that carve out with UHC will require HCFA/CMS 1500. It is unlikely, but there could be a published list of those requiring S9480 be billed HCFA/CMS 1500.

Insurance carriers often are not allowed to inform providers how to bill or which codes to use, unfortunately.

Carriers change billing requirements often, and finding up-to-date information on specific insurance carriers and their billing requirements can be challenging. Each insurance carrier may have their own policies and guidelines regarding billing procedures, including which forms should be used for specific services.

To obtain accurate and current information on insurance carriers that require S9480 (which appears to be a Healthcare Common Procedure Coding System code for PHP/IOP Psychiatric Services) to be billed on the HCFA and CMS 1500 forms, we can help, and recommend reaching out to the specific insurance companies or consulting the provider manuals and billing guidelines provided by those carriers.

Is it possible to submit claims for 90837, 90847, or 90853 along with IOP services?

Normally 90853 is not separated out from IOP per diem claims. Some of the below codes are what Medicare has suggested previously for IOP.

$20 per claim is the Medicare average on occasion because there are normally multiple patients being able to receive benefits in the group for that same service. So theoretically, as medicare and other carriers see this, the provider is being reimbursed for 8-20 patients for the same group 90853 service.

The Centers for Medicare & Medicaid Services (CMS) publish the Medicare Physician Fee Schedule (MPFS) every year, which includes the current procedural terminology (CPT) codes and reimbursement rates for various medical services, including intensive outpatient programs (IOP) for substance abuse.

However, the reimbursement rates may vary based on factors such as geographic location, individual patient characteristics, and other circumstances. It is recommended that you contact Medicare or consult with a healthcare billing professional for more specific information.

That being said, here are some CPT codes commonly used for IOP for substance abuse treatment that Medicare may accept:

H0015: Alcohol and/or drug services; intensive outpatient (treatment program that operates at least 3 hours/day and at least 3 days/week and is based on an individualized treatment plan), including assessment, counseling; crisis intervention, and activity therapies or education

H0016: Alcohol and/or drug services; intensive outpatient (treatment program that operates at least 6 hours/day and is based on an individualized treatment plan), including assessment, counseling; crisis intervention, and activity therapies or education

H0017: Alcohol and/or drug services; intensive outpatient (treatment program that operates less than 3 hours/day and less than 5 days/week), including assessment, counseling; crisis intervention, and activity therapies or education

Please let us know any questions!

How is this indicated on the claim form?

S9840 is a Healthcare Common Procedure Coding System (HCPCS) code used for telehealth services. However, whether or not insurance allows reimbursement for S9480 via telehealth will depend on the specific insurance plan and policy.

To indicate that the service was provided via telehealth on the claim form, you would need to use the appropriate modifier. The modifier for telehealth services is GT, which should be appended to the procedure code (S9480) when billing for telehealth services.

It is important to note that not all insurance plans cover tele-health and even those that do may have specific requirements or limitations. Therefore, it is recommended that you check with the insurance provider or consult the policy documentation to verify coverage and any necessary documentation or requirements for reimbursement.

H0001 and 90791 are two different procedure codes used in mental health services.

H0001 is a HCPCS code used for substance abuse assessment and counseling services. This code is used to bill for substance abuse counseling and treatment services, such as assessments, individual and group counseling sessions, and case management services. H0001 is typically used in the context of substance abuse treatment programs, where the focus is on treating addiction and related issues.

On the other hand, 90791 is a Current Procedural Terminology (CPT) code used for psychiatric diagnostic evaluation. This code is used to bill for initial psychiatric evaluations, where a clinician assesses a patient’s mental health condition, medical history, and related factors to arrive at a diagnosis and treatment plan. 90791 is typically used in the context of mental health treatment, where the focus is on addressing a wide range of mental health conditions.

Therefore, you would bill H0001 when providing substance abuse assessment and counseling services, and 90791 when providing psychiatric diagnostic evaluation services for mental health conditions. It’s important to note that the appropriate code to use may depend on the specific services provided and the requirements of the payer. Therefore, it’s always a good idea to consult with the payer or a coding specialist to ensure that you are billing the appropriate code for the services provided.

One common code for non-intensive outpatient groups for Mental Health or insurance billing for Substance Abuse diagnoses is CPT code 90853.

This code is used to bill for group psychotherapy services, which involve treating two or more patients in a group setting.

To use this code for insurance billing for substance abuse, the mental health provider must conduct a group therapy session that is typically around 60 minutes in length. During the session, the provider works with the group members to address mental health concerns, such as depression, anxiety, or substance use disorders.

It’s important to note that the use of this code is typically limited to certain mental health diagnoses, such as those listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Additionally, insurance companies may have specific requirements or limitations on the use of this code, so it’s always best to check with the patient’s insurance provider before submitting a claim.

Here is the common mistake, not adding the correct modifier. Often times it could possibly be done to use modifier 59 to do 2 groups on the same day, however most carriers don’t allow for the same code on the same day.

Again, The billing code for non-intensive outpatient group therapy for mental health diagnoses is known as CPT code 90853. This code is used to bill for group therapy sessions that are conducted in an outpatient setting, and the therapy is provided by a licensed mental health professional, such as a psychologist, social worker, or counselor.

CPT code 90853 is used for group therapy sessions that typically last for about an hour and are attended by several patients with similar mental health issues. These therapy sessions may focus on a specific mental health diagnosis or issue, such as depression, anxiety, or addiction.

When billing for non-intensive outpatient group therapy using CPT code 90853, the mental health professional must provide documentation that includes the date and duration of the session, the number of patients in attendance, the diagnosis or issue addressed during the session, and a description of the therapy provided.

It’s important to note that insurance coverage for mental health services varies by plan, so it’s important to verify coverage and reimbursement rates before billing for services. Additionally, mental health professionals should be familiar with the specific requirements and guidelines for billing and documentation set forth by insurance companies and regulatory agencies.

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

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

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

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

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

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

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

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

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.

https://www.cmadocs.org/newsroom/news/view/ArticleId/48988/UnitedHealthcare-moving-exclusively-to-electronic-payments

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 UHCprovider.com/payment 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.

Direct-Deposit-Form-STD-LTD-DI Download

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 (ICD–10–CM) 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

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

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

We use several types of demographics:

Facility
Clinical / Medical Director
Patient
Policy holder (can be same as patient)
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

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.

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

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

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.

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.

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.

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.

Depression Causes and Risk Factors

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

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.

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.

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.

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”).