Category: Insurance Billing

Insurance covers eating disorders just like substance abuse depression and anxiety

We are experts at knowing the right codes for the right diagnosis and carrier.
We have a very good pulse on the national averages of reimbursement and will fight for the correct pricing
We are experts in the complexities of insurance billing for eating disorders and mental health.

Most policies will cover eating disorders because it falls under behavioral health coverage

Parity law enforces the coverage of eating disorders.
We check all benefits before admission to determine eligibility.
Give peace of mind to your patients of an idea of what to expect $$$ wise.

Axis can speak to families directly regarding eating disorders and their insurance

We are licensed professionals that actually can advise and enroll patients into the proper health plans.
We can walk patients through the possibility of reimbursement and set expectations.
You have direct access through our online software to see where every claim is processing at any given time.

Out of network benefits can help cover the cost 30%-50% of cash pay clients

Out of network insurance pays above the national average.
No extra processes on your part, we operate within the business operations you have set up.
Increase revenue with no extra work.

Do you ask potential admissions if they are using insurance?

Add insurance reimbursement to your admissions tool belt.
Know the right questions to ask – (we do that).
Have confidence in getting claims processed and paid.

How to do ROP and IOP/PHP claims from the facility and/or treating therapist

We make sure NPI’s are on file and distinguished before submitting claims.
We make sure you are credentialed as in or out of network depending on your contracts.
Negotiate with third party pricing companies pre-billing for ease of processing.

Eating Disorder FCode Example for Insurance Billing

ICD-10-CM Codes
› F01-F99 Mental, Behavioral and Neurodevelopmental disorders
› F50-F59 Behavioral syndromes associated with physiological disturbances and physical factors
› F50- Eating disorders
› 2021 ICD-10-CM Diagnosis Code F50.9

2021 ICD-10-CM Diagnosis Code F50.9

Eating disorder, unspecified

2020-2021 Billable/Specific Code

F50.9 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes.
The 2021 edition of ICD-10-CM F50.9 became effective on October 1, 2020.
This is the American ICD-10-CM version of F50.9 – other international versions of ICD-10 F50.9 may differ.

Applicable To

Atypical anorexia nervosa
Atypical bulimia nervosa
Feeding or eating disorder, unspecified
Other specified feeding disorder

The following code(s) above F50.9 contain annotation back-references that may be applicable to F50.9:

F01-F99 Mental, Behavioral and Neurodevelopmental disorders
F50 Eating disorders

Approximate Synonyms

Eating disorder

Clinical Information

A broad group of psychological disorders with abnormal eating behaviors leading to physiological effects from overeating or insufficient food intake.
A group of disorders characterized by physiological and psychological disturbances in appetite or food intake.
Eating disorders are serious behavior problems. They include
- anorexia nervosa, in which you become too thin, but you don’t eat enough because you think you are fat
- bulimia nervosa, involving periods of overeating followed by purging, sometimes through self-induced vomiting or using laxatives
- binge-eating, which is out-of-control eating
women are more likely than men to have eating disorders. They usually start in the teenage years and often occur along with depression, anxiety disorders and substance abuse. Eating disorders can cause heart and kidney problems and even death. Getting help early is important. Treatment involves monitoring, mental health therapy, nutritional counseling and sometimes medicines.
Group of disorders characterized by physiological and psychological disturbances in eating behavior, appetite or food intake.

ICD-10-CM F50.9 is grouped within Diagnostic Related Group(s) (MS-DRG v38.0):

887 Other mental disorder diagnoses

Convert F50.9 to ICD-9-CM

Code annotations containing back-references to F50.9:

Type 1 Excludes: R13.0

Diagnosis Index entries containing back-references to F50.9:

Anorexia R63.0
- nervosa F50.00
  - atypical F50.9
Aphagia R13.0
- psychogenic F50.9
Bulimia (nervosa) F50.2
- atypical F50.9
- normal weight F50.9
Disorder (of) – see also Disease
- eating (adult) (psychogenic) F50.9
- feeding (infant or child) R63.3 – see also Disorder, eating
  - or eating disorder F50.9
  - specified NEC F50.9
- psychogenic NOS F45.9 – see also condition
  - appetite F50.9

Reimbursement claims with a date of service on or after October 1, 2020 require the use of ICD-10-CM codes.

Eating Disorder Billing Codes for Insurance

Facility/Program Universal Services List	Preferred Codes for UB‐04 Billing	Preferred Codes for CMS 1500 Billing
USL #	Standard Services	Revenue Code	Type of Bill Code	CPT/HCPCS Codes	HCPCS Modifier	CPT/ HCPCS Codes	HCPCS Modifier
	Hospitalization
1.1	Hospitalization, Psychiatric	0114, 0124, 0134, 0144, 0154				N/A ‐ Bill inpatient services on UB‐04 form
1.2	Hospitalization, Substance Use Disorders, Rehabilitation Treatment	0118, 0128, 0138, 0148, 0158				N/A ‐ Bill inpatient services on UB‐04 form
1.3	Hospitalization, Substance‐Induced Disorders	0118, 0128, 0138, 0148, 0158				N/A ‐ Bill inpatient services on UB‐04 form
1.4	Hospitalization, Substance Use Disorders, Detoxification	0116, 0126, 0136, 0146, 0156				N/A ‐ Bill inpatient services on UB‐04 form
1.5	Hospitalization, Eating Disorders	0114, 0124, 0134, 0144, 0154				N/A ‐ Bill inpatient services on UB‐04 form
1.6	Hospitalization, 23 Hr Bed, Psychiatric	0762				N/A ‐ Bill inpatient services on UB‐04 form
1.7	Hospitalization, 23 Hr Bed, Substance Use Disorders, Rehabilitation Treatment	0762				N/A ‐ Bill inpatient services on UB‐04 form
	Residential Treatment
2.1	Residential Treatment, Psychiatric	1001		H0017 or H0018		H0017 or H0018
2.2	Residential Treatment, Substance Use Disorders, Rehabilitation Treatment	1002		H0011		H0011
2.3	Residential Treatment, Eating Disorders	1001		H0017 or H0018		H0017 or H0018
	Partial Hospitalization
3.1	Partial Hospitalization, Psychiatric	0912 or 0913		H0035		H0035
3.2	Partial Hospitalization, Substance Use Disorders, Rehabilitation Treatment	0912 or 0913		H0035		H0035
3.3	Partial Hospitalization, Eating Disorders	0912 or 0913		H0035		H0035
	Intensive Outpatient Treatment
4.1	Intensive Outpatient, Psychiatric	0905		S9480		S9480
4.2	Intensive Outpatient, Substance Use Disorders, Rehabilitation Treatment	0906		H0015		H0015
4.3	Intensive Outpatient, Eating Disorders	0905		S9480		S9480
Facility/Program Universal Services List	Preferred Codes for UB‐04 Billing	Preferred Codes for CMS 1500 Billing
	Outpatient
5.1	Outpatient Therapy Services, Psychiatric/Substance Use Disorders	0914 0915 0916		Use appropriate CPTs		Use appropriate CPTs
5.2	Outpatient Aftercare (“Bridge Appointment”) Program	0513
5.3	Applied Behavior Analysis (Autism)			Applicable CPT codes for ABA services		Applicable CPT codes for ABA services
5.4	Electroconvulsive Therapy (ECT)	0901		90870		90870
5.5	ECT Anesthesia	0901		00104		00104
5.6	Ambulatory, Substance Use Disorders, Detoxification	0944 or 0945		H0014		H0014
5.7	Ambulatory, Substance Use Disorders, Buprenorphine Maintenance.	0944		H0001 H0014	HG HG	H0001 H0014	HG HG
5.8	Methadone Maintenance	0944 or 0529		H0020		H0020
5.9	Crisis Stabilization	0900 or 0914		S9485		S9485
5.10	Emergency Room	045x		99281 ‐ 99285		99281 ‐ 99285
5.11	Injections			96372		96372
5.12	Home Health Therapy Services	058x		Applicable CPT codes		Applicable CPT codes
5.13	Nursing Home/Domiciliary or Rest Home Visit	N/A		Applicable CPT codes		Applicable CPT codes
	Ancillary Services
6.1	Telehealth Administrative Services	078x		Q3014		Q3014
6.2	Non‐Emergency Transportation			S0209 S0215 A0100		S0209 S0215 A0100
6.3	Emergency Transportation / Ambulance Service	054x		A0021 A0999		A0021 A0999
6.4	Interpreter Services			T1013		T1013
6.5	Laboratory services	030x		H0003 H0048		H0003 H0048

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

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

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

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

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

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

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

Billing for IOP in a nutshell

Are you seeing changes in IOP billing for mental health in 2023? We certainly are. There are new requirements coming from UHC, BCBS, Cigna, Aetna and all the rest for all levels of care including RTC and PHP billing all the way through outpatient services.

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

Behavioral health levels of care

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

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

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

Typical services covered in IOPs

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

Typical services generally covered are:

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

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

The attending provider must supervise the patient at all times.
Adhering and being consistent with the initial treatment plan for the patient.
Addressing the diagnosis(s) that required admission.
Being consistent with clinical best practices. (Clinical are an important determining factor in authorization and concurrent authorization for the patient.)
Having a responsible expected time to treat the patient, generally allowing between 12 to 16 weeks of IOP care.

HCPCS and revenue codes for IOPs

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

A psychiatrist once said,

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

“Let us all work together to stop this epidemic from spreading and killing our loved ones.”

As we all know, prescription drug abuse has become an epidemic all across the nation. However, Utah has become one of the nation’s leading states for drug abuse, ranking fifth in the nation for prescription drug overdoses from 2013 to 2015.

Since 2007, the Legislature has passed 101 laws addressing prescription misuse, monitoring prescribing practices, overdose prevention with an emergency drug called naloxone, and court-ordered treatments.

There is also a database known as Utah’s prescription drug monitoring system, which was created in 1995 to assist doctors and law enforcement monitor the use and abuse of prescribed controlled substances. Utah is one of 48 states with a system like this in place, but many other states require law enforcement to obtain a warrant or court order to access the database, however, Utah is not one of them.

In 2012, an average of 21 Utah adults each month died as a result of prescription drug use. Fatal prescription pill overdose is known more commonly in Utah than death by car crash. Most people have the assumption that just because they get prescribed painkillers from a doctor that it is safe to use anytime when in reality this is just not true and can be very fatal.

Since 2002, deaths from prescription pain medication outnumbered heroin & cocaine deaths combined. Nearly half of young adult heroin users reported having first abused prescription opioids. Only 15% of addicts get the treatment they need.

These are alarming facts about prescription drug abuse in Utah, and if you or a loved one is suffering from addiction, please reach out to a treatment center that can help you. There is no better time to get the help you need then now. With awareness and knowledge available nowadays, we can all help stop this horrible epidemic.

Outsourcing your behavioral health insurance billing? Here is what you need to know.

So you think to yourself, “How good it would be if I could just focus more on treating patients, and not have to worry about back office practices.” Well I have a solution to your problem, and its called outsourcing your insurance billing, and it can help relieve the stress and pressure so you can do what you really want to do, help your patients and focus on treatment.

However, just like any other big decision, you want to make sure you pick the right company or it may be more hindering than before.

Take things into consideration like:

- what is their track record,
- do they have a good reputation within the industry,
- and what are their best practices and operational functions with the company.

Being well prepared upfront can help avoid any misunderstanding about what your needs, budget, and goals are — and how they can help you achieve those.

Do they really know behavioral health billing inside and out?

If you have already been managing your behavioral health billing, you know of the daily obstacles that occur and the need to know-how, to overcome and tackle those issues. Make sure the company is seasoned with the knowledge needed to get the job done right. There are coding protocols and standards that must be met to avoid denials and delay of claim payment.

I look at it like this, my Grandma used to say, “You’re only as good as the company you keep”, so in regards to finding a good company, don’t be scared to ask for references. Successful and happy references go a long way when coming down to making the last decision.

Are their employees really experts at what they do?

Ask questions about who’s responsible for what, and how the processes are done step-by-step until you are satisfied. A good company will equip all of their employees with the proper training, certification, and continuing education requirements to be registered and maintain their licenses. Healthcare laws passing and changing ever so frequently, it’s very important that the company is always up-to-date on those rules, regulations and Current Procedural Terminology (CPT).

To really get an understanding, ask about their internal operations, and what is the chain of command in case of an escalated situation that may occur. How and who handles what it those types of quandaries.

How safe will your patients information be?

Standards are essentially mandatory when it comes to protecting patient information in the healthcare industry. Always make sure when dealing with companies that they meet and are up to date with the Health Insurance Portability and Accountability Act (HIPPA) also the Office of the Inspector General (OIG) and the Occupational Safety and Health Administration (OSHA).

Your patients privacy should always come first, and the company you choose should be able to explain how they protect patient information. We live in virtual world where identity theft is real, and the threat is always trying to find new ways to access records and other pieces of personal information. Knowing that, what are the steps that the company takes to prevent such things happening to them?

Is there one individual that’s the compliance officer or is it a group or committee that makes these decisions and enforces the privacy controls. From ensuring all emails are encrypted, the processes for general billing and home-based employees.

What kind of reports do they generate and are you granted access to them?

A lucrative billing company knows that reports are a functional asset to your success and they should have reports in place currently to where you can request sample reports. A forward thinking billing company should have their own software that helps with operations, insurance billing, and reporting. Have them give a demo of their internal operations, billing, or reporting software.

Insurance billing software should be designed to make the role of the facility easier – and more streamlined.

Tracking charges and payments, putting together performance indicators will assist your own metrics to help with:

If claims are being paid within your expectations.
Track which carriers are paying more frequently compared to others.
How are your business processes are performing.

How are they paid, or what are their fees for service?

Not every company has the same structure when it comes to being paid. Either they will charge you a percentage of the charges or receipt, or they may just charge a flat rate or monthly retainer fee. Always ask if there is are start-up fees and or administrative fees that you would need to pay also.

Just a heads-up, you will want to discuss with your partner’s how much you are wanting to spend for outsourcing billing before you even have this conversation with them. It will avoid any non-sense fees and gives the company a idea of what your budget is initially. The expectation of them getting things done in professional, smooth, and confidential manner will ultimately determine which billing company to go with.

Just remember to ask as many questions as you can and being prepared ahead of time will help you partnering up with the perfect third-party billing company. When you choose an insurance billing company, you are building a trusting relationship with them.

We want to be that company that builds that trust with you.

The Secrets to Claims Follow Up

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

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

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

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

- The facility Tax Identification number (Tax ID)
- National Provider Identification number (NPI)
- Insured’s name

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

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

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

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

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

The “Ten Commandments of Insurance Billing Questions”

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

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

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

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

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

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

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

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

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

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

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

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

Well you may need information or help from the patient?

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

Here are a few ways to handle this step:

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

Revenue Cycle Management 101

Like many other industries, drug rehab and mental health treatment facilities’ financial solvency depends largely on their ability to collect payment in a timely fashion. In order to ensure your receivables are collected in a timely fashion, it is imperative to either have an in-house billing team that runs like a well-oiled machine, or find a stellar third party billing partner.

When it comes to operations in the behavioral health industry, Revenue Cycle Management is not normally the first thing that comes to mind. However, as this industry continues to become more competitive, streamlining your billing operations is crucial. This guide will help outline this process.

Revenue Drivers for Behavioral Health

Hopefully, during the strategic planning of your program, key revenue drivers have been established. These revenue drivers are dependent on your program’s specific type of business model: inpatient or residential vs. outpatient.

There are similarities in foundational revenue drivers in terms of substance abuse and mental health insurance reimbursement. These start even before a potential client steps one foot in the door and can continue long after they are gone:

Verification of mental health and substance abuse benefits (all levels of care).
Detailed clinical note taking, proper record keeping, communication between line and clinical staff.
Billing and submitting claims, payment tracking, client account administration, and denials management (including underpaid and missed claims).

The ability of your program to execute all these tasks in a consistent and efficient manner is directly reated to the amount and timeliness of which you will receive reimbursement.

Staff-to-client efficiency
Census level
Cost of programming
Claims reimbursement from both Medicaid/Medicare and private health coverage
Client claims (coinsurance, copayments, deductibles, etc.)
Collections

These internal drivers are all controllable and can be easily improved upon with some consistent processes and follow-through. Where many organizations struggle is dealing with the more external variables, like collecting from insurance carriers, patients/families, and other payers.

When trying to optimize your revenue cycle, you have to take into consideration the existing setup of private and insurance pay processes. Insurance carriers can take weeks to reimburse stays at behavioral health facilities.

Each individual entity will have their own method of checks and balances to both make sure their policy member is in need of treatment, and how much and how often reimbursements will be paid.

There are many facilities that operate from a dated business model: payment can be made after services have been rendered. Although this approach can help with increasing census, it will end up with longer collection times and ultimately a payment level that equals less than the full cost of care.

Pre-paying and Reimbursements

Claims, claims, claims. There is a reason third party billing exists, and that there are experts within all the different areas of billing. Insurance claims reimbursement—especially for mental health and substance abuse—is not a simple process. It is also an increasing, major portion of a facility’s overall revenue (compared with private cash pay).

Claims reimbursement starts with proper claims management.
- This process involves meticulous note-taking
Reimbursement rates negotiation – all levels of care including:
- Inpatient
- Residential Treatment (RTC)
- Partial Hospitalization (PHP)
- Intensive Outpatient (IOP)
- Routine Outpatient (ROP)

The negotiation of contracted rates for behavioral health reimbursement can vary state-by-state and region-by-region. There are different laws and regulations that govern not only how care is administered, but also how it is paid for and reimbursed by insurance carriers.

Navigating these waters is a full-time job in and of itself. If your program does not have room or resources for a dedicated staff member or in-house team, it is best to connect with outside experts.

This includes an organization that is knowledgeable and understands:

The lengthy legal appeals process
The ins and outs of coding
The subtleties of mental health and addiction language
Timely filing and follow up
Quality assurance

A common occurrence with insurance claims is that they are either fluctuating and underpaying or not paying at all. If someone is not watching these claims on a day-to-day basis, it can be difficult to keep your revenue cycle management on point.

A recent in-depth report by 60 Minutes found the claim denial rate often exceeded 90% by Anthem in cases it reviewed.

Even facilities that are running their billing operations as smoothly as possible can still face an uphill battle to keep a solid, timely, and full amount of reimbursements coming in. Rejection rates are going to continue to rise as insurance becomes more and more expensive.

The other factors involved in keeping a solid revenue cycle from insurance reimbursement are the other payables: deductibles, co-pays, and co-insurance. Because of the recent spike in health insurance premiums, there is a correlating rise in people taking on more of the share of the cost. This means that your cash pay collection processes will be put to the test as well.

Collections and Margins

In order for any type of collection to make sense, it has to make cents. It does no good to go after receivables or debts that cost you more to get them then they are worth.

More than likely, the lion’s share of your revenue will come from reimbursement; however, most of the work put into collections will be in getting private pay clients to pay for services rendered.

You have to realize that private health insurance paying for drug rehab or therapeutic boarding schools is a relatively new concept. This option essentially did not exist before the Affordable Care Act was put in place. Because of this, debt collection from insurance reimbursement is now a severe pain point for behavioral health facilities.

For instance, with Blue Cross Blue Shield, all reimbursement checks are sent to the family and not the facility. This creates an additional step in the process, and a huge problem/delay in revenue collection. Because the insurance process is complex and cumbersome, many parents do not realize that the reimbursements they receive are not theirs, and it puts tension on all parties involved.

There was and still is a huge learning curve for proper and diligent insurance billing. In order to maximize allowable amount of reimbursement, it is essential to closely watch the accounts owed for all of the major insurance carriers.

It takes a serious amount of resources, including staff who can:

Take the time to research insurance trends
Educate themselves on claims processing for each major carrier (BCBS, Aetna, UBH, Cigna)
Understand how in-network/out-of-network contracts work
Apply all this working knowledge to recognizing:
- When to be forceful with outstanding claims
- When to adjust private and insurance pay rates
- Why denials are occurring

A good revenue cycle in this industry should never get beyond 40-50 days.

If there are enough resources allocated to keeping things organized and processes flowing smoothly, this should not be a problem.

To summarize, a facility must streamline:

Verification of benefits
Collection of any co-insurance, co-pay, or deductible up front
Utilization reviews
Referral management system
Claims follow-up
Denials management

The Right Resources for the Right Job

The world of healthcare and healthcare billing is a complex one—a world that, by its very nature, works backwards, and involves extreme delays in payment cycles. Even with these long payment cycles, you should be taking some steps to accelerate the process, or to at least minimize unnecessary delays. Otherwise, an average of 40-50 days for payment can turn into 90-120 days.

Here are some tools you can use:

Roadmap

Think of billing as a chain-linked process. All of those involved with an insurance pay client, including the initial touchpoint, have to understand the entire roadmap from start to finish.

Everyone involved needs to be able to understand what codes will be used, the process of filing a claim, and whether or not their health plan will be a good fit upfront.

Software, The Web, and Being Mobile

Electronic Health Records
Client Relationship Management
HIPAA Compliance
Mobile Friendly

Knowing these technical terms is instrumental not only in streamlining a facility’s revenue cycle, but also in conducting overall operations. There are many options in the HealthTech world, and which software you want to use will depend on the size and needs of your facility.

Once you choose the correct technologies for your needs, here are some helpful hints to speed up the revenue cycle:

VOB

Verify insurance online through the carrier portals in order to avoid long call wait times, and be sure to double-check benefits.

Payments

Collect all insurance payables upfront and offer to reimburse clients after insurance has made payments.

Tracking Patients

Training therapists and support staff to properly document their client encounters, admissions, and discharges with quick notes and details.
Make sure clients have primary diagnoses as well as secondary diagnoses if warranted.

Insurance Billing

Once you have submitted a claim, make sure someone is following up within at least 72 hours to make sure it has been accepted by the clearing house and processed by the carrier.
Insurance billing reporting will allow you to forecast financials and show trends in health care plans, diagnoses, payment cycles, and much more. Make sure whatever billing software you use has a solid reporting functionality.

This is all easier said than done. It requires a quality team of reliable professionals dedicated to keeping your facility running as efficiently as possible. Your revenue cycle management should be a living, breathing process that is constantly revisited, adapted, and updated. Don’t get complacent!

Why do people get into the addiction and mental health treatment industry?

For the most part it is because they have some sort of connection – either personally or a direct relative or friend that has been afflicted by a devastating behavioral health condition.

You can ask 1,000 CEO’s, Owners, and Program Directors and not one of these industry leaders will tell you the primary reason they felt a calling to help people with addiction or mental health issues was because the revenue potential.

With that said – it takes a community to help addicts get better. A community of highly educated, highly skilled and experienced professionals who are dedicated to the well being of others. In a perfect world these pillars of the treatment community would be able to provide their services at little or no cost, however this is not the case – their highly specialized skill set is in high demand by those in need.

The good news is that insurance carriers have plans and benefits that cover both addiction and mental health treatment – and with the Affordable Care Act, more people then ever have the ability to access these benefits.

There is a simple math equation here that can show how to drastically increase your rehab facility profits – many families have insurance benefits that can pay for a longer stay – with a much more needed step down in continuum of care – than they can afford to simply pay for out of pocket.

Get accredited

Implement strong tracking processes

Learn the language of insurance

Communicate internally

Advocate for your patients

Educate your families

To be continued.