Category: Insurance Billing

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.

Prepare for the call and make SURE to input all necessary information at the step in the system. Remember, do all work at the steps.

Confirmatory Questions

1. Patient Birthdate?

2. Phone Number?

3. Confirms the NPI?

4. Confirm tax ID?

Medical Information Questions

5. How many hours a week for how many hours a day?

6. Asks to confirm the diagnosis codes

7. Any medical conditions?

8. Pregnant or Postpartum?

9. What brought member into this facility?

10. “Any support at home?”

11. Does member go to school or work?

12. Legal issues?

13. Trauma History?

–Potential follow-up questions about whether or not incidents were reported—

14. Substance Abuse notes?

15. Any family mental illness and psychiatric history?

16. Asks about previous treatment history.

17. MSE upon admission?

18. ADL’s?

19. What medications did member come in with/current/changes and what are the dosages?

20. Member compliant with the meds that we know of?

21. What are the goals while member is there with you?

22. Safety precautions for member at this time?

23. What is the discharge plan?

24. Is the facility communicating with outpatient providers? Who are they?

25. Has member agreed to the current treatment plan?

26. Has member named an outpatient provider?”

– Then they issue the approval

To obtain authorization for behavioral health services, follow these steps:

Check your insurance plan: Before seeking behavioral health services, check your insurance plan to determine if prior authorization is required. Some insurance plans require pre-authorization for certain types of services or for services provided by specific providers.

Choose a provider: Choose a behavioral health provider who is in-network with your insurance plan. If you choose a provider who is out-of-network, your insurance may not cover the cost of the services or may require you to pay a higher out-of-pocket cost.

Contact your insurance company: Contact your insurance company to initiate the authorization process. You may need to provide some basic information, such as your name, insurance plan details, and the type of service you are seeking. The insurance company may also require additional information, such as the provider’s name, the reason for the service, and the expected length of treatment.

Obtain authorization: Once your insurance company has reviewed the request, they will either approve or deny the authorization. If approved, the insurance company will provide you and your provider with an authorization number, which you will need to give to the provider before receiving services. If denied, you may need to appeal the decision or seek alternative services.

It is important to note that the authorization process can take some time, so it is best to start the process as soon as possible to avoid delays in receiving treatment. Also, be sure to follow up with your insurance company and provider to ensure that the authorization has been obtained before scheduling appointments.

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

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

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

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

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

What are CPT codes?

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

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

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

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

How to know what psychotherapy codes to use?

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

Coding tips when billing for mental health services.

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

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

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

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.

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

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

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

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

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

Earlier Changes Made to ACA

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

Elimination of the Individual Mandate

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

Work Requirements Added to Medicaid

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

The Ending of Cost-Sharing Reduction Subsidies to Insurance Providers

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

Expansion of Short-Term Plans

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

Slashed Budgets for HealthCare.gov Sign-Ups

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

The Impact That ACA Has on Substance Abuse Treatment

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

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

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

Billing and Reimbursement for Behavioral Health Service Providers

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

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

Hospital-Based and Residential Inpatient Care

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

Partial Hospital Programs (PHP)

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

Intensive Outpatient Programs (IOP)

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

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

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

Other Key Takeaways

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

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

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

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

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

PHP 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.

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

Outpatient can be considered both PHP and IOP

131: admit through discharge

132: interim-first

133: interim-continuing

134: interim-last

CAH

851: admit through discharge

852: interim-first

853: interim-continuing

854: interim-last

CMHC

761: admit through discharge

762: interim-first

763: interim-continuing

764: interim-last

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

Sequential Billing

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

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

Insurance 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.

What You Need to Know for PHP Insurance Billing in 2023

A partial Hospitalization Program (day hospitalization) is a structured day program providing several hours of therapy and necessary skill-building groups daily. Participants in a daily PHP routine go back home each night. The program can last for a week or up to six months.

PHP treatment programs closely resemble a highly structured but short-term hospital inpatient program. It’s more intense than psychosocial rehabilitation or outpatient day treatment. We have prepared this article to provide general guidelines for insurance billing for PHP.

Behavioral Health Levels of Care

Behavioral health facilities provide four types of services needed by patients that insurance companies may reimburse. These include:

Hospital-based inpatient programs where patients need medical monitoring, nursing care, or other behavioral health services requiring 24/7 treatment.
Residential treatment programs (RTC) are a form of sub-acute facility-based monitoring that offers other behavioral health services.
Partial hospital programs (PHP) provide services in an ambulatory setting and often require 20 hours per week.
Intensive outpatient programs (IOP) where patients get behavioral health services for nine to 19 hours per week (adults) and at least six hours for children and adolescents.

Insurance Billing for PHP in a Nutshell

PHP services receive insurance reimbursement for an all-inclusive per diem payment, including services used in the program or the lesser charges. It includes all disciplines and services such as therapies, social workers, psychiatric nurses, dieticians, occupational therapists, and licensed addiction counsellors.

Psychologists, psychiatrists, psychiatrist physician assistants, and psychiatric nurse practitioners may bill separately on a CMS-1500 Claim Form if they provide services outside of a treatment program, for example, individual therapy, E&M services, or psychological testing. Additionally, appropriately licensed providers can bill separately for labs or psychiatric diagnostic evaluations.

Providers cannot bill Family or group counseling in addition to PHP.

Instructions for Insurance Billing for PHP

Facilities provide different substance use and psychiatric service levels with various licensure types. Each care level requires specific coding and billing information to determine appropriate reimbursement. Below is the insurance billing for PHP guide on the UB-04 Claim Form.

Psychiatric Services

Facility or Service Type	Bill Type	Revenue Code	Level	HCPCS
PHP	131	0912	Full day	H0035
PHP	131	0912	Eating Disorder Program	S9485

Substance Use Services

Facility or Service Type	Bill Type	Revenue Code	HCPCS
PHP	131	0912	S9475

Billing Limitations and Exclusions

When insurers consider reimbursement, payment determination is subject to the following:

Individual or group benefit
Provider Participation Agreement
Mandated or legislative-required criteria always supersede
Routine claim editing logic that includes but not limited to mutually exclusive or incidental logic and medical necessity

If the insurance provider participates based on member benefits, then coinsurance, co-payment and deductible apply.

Does Medicare Cover PHP?

Medicare could cover PHP programs if a Medicare-certified CMHC or a hospital outpatient department provides them. Medicare does not cover psychosocial programs that provide only socialization, vocational rehabilitation, or a structured environment. A program comprised primarily of social, recreational, or diversionary activity does not constitute a PHP.

Patients that meet benefit category requirements for PHP Medicare coverage comprise of two groups:

Those discharged from inpatient hospital treatment programs where PHP is in place of a continued inpatient treatment
Those who would be at risk of needing inpatient hospitalization in the absence of PHP

Over to You

Reimbursement policies for insurance billing for PHP are intended to establish general guidelines under the specific insurance providers’ plans. Therefore, providers retain the right to review and update reimbursement policy guidelines at their discretion.

We hope this short but informative article was helpful. If you have any queries about insurance billing for PHP and how to maximize your reimbursement, please contact us via email or our contact us website page.