Category: Revenue Cycle Management

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

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

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

We use several types of demographics:

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

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.

help with insurance billing for drug rehab

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.

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:


Diagnosis Index entries containing back-references to 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 BillingPreferred Codes for CMS 1500 Billing
USL #Standard ServicesRevenue CodeType of Bill CodeCPT/HCPCS CodesHCPCS ModifierCPT/ HCPCS CodesHCPCS Modifier
Hospitalization
1.1Hospitalization, Psychiatric0114, 0124,
0134, 0144,
0154		N/A ‐ Bill inpatient services on UB‐04 form
1.2Hospitalization, Substance Use Disorders, Rehabilitation Treatment0118, 0128,
0138, 0148,
0158		N/A ‐ Bill inpatient services on UB‐04 form
1.3Hospitalization, Substance‐Induced Disorders0118, 0128,
0138, 0148,
0158		N/A ‐ Bill inpatient services on UB‐04 form
1.4Hospitalization, Substance Use Disorders, Detoxification0116, 0126,
0136, 0146,
0156		N/A ‐ Bill inpatient services on UB‐04 form
1.5Hospitalization, Eating Disorders0114, 0124,
0134, 0144,
0154		N/A ‐ Bill inpatient services on UB‐04 form
1.6Hospitalization, 23 Hr Bed, Psychiatric0762N/A ‐ Bill inpatient services on UB‐04 form
1.7Hospitalization, 23 Hr Bed, Substance Use Disorders, Rehabilitation Treatment0762N/A ‐ Bill inpatient services on UB‐04 form
Residential Treatment
2.1Residential Treatment, Psychiatric1001H0017 or H0018H0017 or H0018
2.2Residential Treatment, Substance Use Disorders, Rehabilitation Treatment1002H0011H0011
2.3Residential Treatment, Eating Disorders1001H0017 or H0018H0017 or H0018
Partial Hospitalization
3.1Partial Hospitalization, Psychiatric0912 or
0913		H0035H0035
3.2Partial Hospitalization, Substance Use Disorders,
Rehabilitation Treatment		0912 or
0913		H0035H0035
3.3Partial Hospitalization, Eating Disorders0912 or
0913		H0035H0035
Intensive Outpatient Treatment
4.1Intensive Outpatient, Psychiatric0905S9480S9480
4.2Intensive Outpatient, Substance Use Disorders, Rehabilitation Treatment0906H0015H0015
4.3Intensive Outpatient, Eating Disorders0905S9480S9480
Facility/Program
Universal Services List		Preferred Codes for UB‐04 BillingPreferred Codes for CMS 1500 Billing
Outpatient
5.1Outpatient Therapy Services, Psychiatric/Substance Use Disorders0914
0915
0916		Use appropriate CPTsUse appropriate CPTs
5.2Outpatient Aftercare (“Bridge Appointment”)
Program		0513
5.3Applied Behavior Analysis (Autism)Applicable CPT codes
for ABA services		Applicable CPT codes
for ABA services
5.4Electroconvulsive Therapy (ECT)09019087090870
5.5ECT Anesthesia09010010400104
5.6Ambulatory, Substance Use Disorders,
Detoxification		0944 or
0945		H0014H0014
5.7Ambulatory, Substance Use Disorders, Buprenorphine Maintenance.0944H0001 H0014HG HGH0001 H0014HG HG
5.8Methadone Maintenance0944 or 0529H0020H0020
5.9Crisis Stabilization0900 or
0914		S9485S9485
5.10Emergency Room045x99281 ‐ 9928599281 ‐ 99285
5.11Injections9637296372
5.12Home Health Therapy Services058xApplicable CPT codesApplicable CPT codes
5.13Nursing Home/Domiciliary or Rest Home VisitN/AApplicable CPT codesApplicable CPT codes
Ancillary Services
6.1Telehealth Administrative Services078xQ3014Q3014
6.2Non‐Emergency TransportationS0209
S0215 A0100		S0209
S0215 A0100
6.3Emergency Transportation / Ambulance Service054xA0021
A0999		A0021
A0999
6.4Interpreter ServicesT1013T1013
6.5Laboratory services030xH0003
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.

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

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

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

Typical services covered in IOPs

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

Typical services generally covered are:

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

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

HCPCS and revenue codes for IOPs

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

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

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

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

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

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

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

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.

how to bill for insuranceTake 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?

denials managmentAsk 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.

 

behavioral health insurance billingHow 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.

These simple fixes could save thousands of dollars and dozens of headaches. Work them into your billing processes!

Is your treatment center experiencing financial difficulties? There are many billing errors that can cause claims to be denied. Payments being delayed, incurring fines, and revenue loss can all happen due to errors not being caught before submitting claims. So before you start sending your claims out, beware or the most common mistakes.

 

  1. Having a brain lapse and forgetting to verify insurance

Believe it or not, the top reason why most claims are denied is because there was no initial verification of benefits and coverage. We all know insurance can change for whatever reason. So it is crucial that the provider verifies it every time services are rendered. When you don’t verify insurance properly, things like are overlooked like.

  • Members coverage may be terminated
  • The service isn’t even authorized in the first place
  • The plan benefit doesn’t cover the service being rendered
  • The Lifetime Maximum benefit has been met

 

  2. Inaccuracies in the Patient’s File

You would be surprised how something as simple as a patient’s name being misspelled, or having the wrong date of birth, or is this the patient relationship status to the insured correct, also using a policy number that is invalid can cause claims to be denied upfront. However there are some pieces of information that aren’t so clear and easy to notice like.

  • The claim requiring a group number to be entered
  • Making sure the diagnosis code matches with the procedure code
  • If there are multiple insurances, making sure the primary insurance is right for coordination of benefits

You don’t want to have to miss one of these simple pieces of information — making the claim go from say a 1-2 week turnaround, to a 30 to 45 days before the claim is paid.

3. Not using the Correct Diagnosis or Revenue/HCPC Codes on Claim

Like stated above making sure the diagnosis and procedure codes match are very important, but more importantly you want to be sure the codes being used are actually correct. This is how the insurance company knows the symptoms, disorders and how they are being treated by the facility. Incorrect information can result in a immediate denial of the claim for not being medically necessary, or it doesn’t match the authorization given for treatment.

Couple of things to consider as to why the wrong diagnosis or procedure code could be submitted resulting in denial.

  • Your Coding books are out of date and you’re using old protocols that have been revised. They can be pricey but is it really worth losing revenue on avoidable denial errors?
  • You might laugh, but if you handwriting is not up to par and causing claims to be denied because of horrible penmanship, you should really consider switching from paper claims to a electronic submission.

 

4. Duplicate Billing

Duplicate billing is just what it sounds like, billing for the same service or treatment  on more than one claim. It can also be considered as billing for a procedure that wasn’t even performed in the first place. It is very key to perform Chart audits for all patient’s to ensure claims are being billed out correctly. Ultimately you want to try and limit this to none, as facilities are fined each year for these small mistakes and considered as committing fraud. Ouch!

 

5. Misrepresenting Level of Care

This occurs when you the level of care is incorrect in order to receive a higher reimbursement rate from the insurer, also referred to as up-coding. Claims are looked at in fine detail to it’s better to just not do, or once again it will deny and stall the claim payment.

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:

  • 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:

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

appeal letter for insuranceA 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:

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!