Muhammad Sair Khan
Behavioral Health Guide to Quick and Accurate Claims Processing
Billing for behavioral health services, or any medical care, is a complex process. To ensure your claims are paid, you need reliable billing processes, detailed clinical notes and the time to consistently follow up with insurance companies. Even one wrong code can hurt your revenue, resulting in denied claims and delay in payment.
Receive the highest reimbursements for both inpatient and outpatient services by following this guide to behavioral health billing.
INTAKE ASSESSMENT FOR BEHAVIORAL HEALTH
A comprehensive intake assessment includes all the information you need to actively manage a patient’s billing during their care. When you admit a patient, you should:
Make a copy of their ID and insurance card.
Get an up-to-date address and phone number.
Collect deductible and admission fees.
Have them sign the appropriate forms, including:
Release of Information for future issues with billing
Consent to Treat
Power of Attorney
Coordination of Benefits
Financial Assignment of Benefits
HIPAA Notice of Privacy Practices
Authorization to Appeal on Behalf of Patient
Parent/Guardian Signature (minor only)
A thorough intake assessment gives you the information you need to receive prior authorization. It also gives you the opportunity to inform the patient of their financial responsibilities. It’s the first step to an efficient billing process.
DETERMINE MEDICAL NECESSITY
Before you request prior authorization and begin treating your patient, you need to understand how insurers determine medical necessity. If they determine a service or specific level of care is not medically necessary, it’s unlikely they will pay your claim in the future.
By definition, medical necessity is any health care service that is needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms. To make this determination, claim adjusters ask:
Are the services based on credible, scientific evidence recognized by the medical community?
Are the services clinically appropriate regarding type, frequency, and duration?
Is the service effective for the illness it is treating and not more costly than an alternative service?
Your utilization review (UR) specialist and case manager should keep these questions in mind as they pursue prior authorization for a patient’s services. They should also use the American Society of Addiction Medicine (ASAM) criteria to help determine what level of care and length of treatment the patient needs. These guidelines help insurance companies understand medical necessity and determine what is covered by patients’ plans.
Your UR specialist should use ASAM criteria to communicate with the insurance companies and get the right treatment authorized for each patient. Your UR specialist will be most effective if he or she has a clinical background.
VERIFICATION OF BENEFITS / PRIOR AUTHORIZATION
Once you determine that the patient is the right fit for your facility, you’ll need to obtain prior authorization for their care from their insurance company. You can start this process by verifying your patient’s benefits. However, covered benefits vary from payor to payor and with each individual insurance plan. The language in insurance policies can be convoluted and difficult to understand.
There are tons of software companies that offer instant verification of benefits but because insurance policies are so complex, these electronic systems are not always accurate. It is best that you call the insurer to verify that the service you want to provide is covered, even if it shows as being covered online. Talking to a representative on the phone will take more time, but it will also ensure that each aspect of your patient’s planned care is covered.
Always get a reference number from the representative who quoted your patient’s benefits.
To get prior authorization for your patients, you should:
Call the insurer within 24 hours of admission.
Refer to relevant documents that you received during the intake assessment.
Stay organized. Keep a separate file for each patient with a record of any details or critical information you received from the case manager as well as their prior authorization number.
Take notes while you are on the call receiving prior authorization including the representative’s name, the date, the call reference number, and the authorization number.
Monitor your patient’s policy to ensure its active. If a policy lapses while they are under your care, the services will no longer be covered.
Without prior authorization, the insurance companies may deny your claims. It is still possible for companies to deny or not pay claims, even with prior authorization; that’s why you need to stay organized with every patient.
In addition to getting prior authorization when a patient is admitted, your UR specialist will also need to provide timely follow-up to get additional days authorized. This is where it is extremely beneficial to have a UR specialist with a clinical background.
The more detailed your UR specialist is, the more likely they are to get more days authorized for your patient so they can get better--and you can get paid. You should be able to get more days authorized if:
You uncover underlying psychological issues that need more attention and care.
You properly use the ASAM criteria to describe your patient.
Your UR specialist is ready to strongly advocate for the patient.
Revenue Cycle Management
Your revenue cycle begins the moment the patient is admitted for care and doesn’t end until you’ve received payment for all of their services. Proper revenue cycle management leads to faster payment and fewer unpaid or denied claims. You need to pay close attention to each aspect of your revenue cycle:
Accurate Patient Information
Starting with front desk staff, you should ensure all staff members are verifying and checking patient information regularly. Even the smallest typo in a patient’s name can lead to an unpaid claim. Before admission, your front desk staff should verify:
Primary and secondary insurance information
Any co-pays the patient is responsible for
Any deductibles the patient is responsible for
Patient’s name, address, and birth date
Sometimes a patient’s insurance policy will term during their treatment. This can be because they failed to pay their monthly premium or their coverage expired. It is a best practice to continue verifying benefits throughout the patient’s stay.
If you use the comprehensive intake assessment procedures mentioned above, you have set yourself up for a successful revenue cycle.
Monitor Claims Reports
You should monitor your company’s financial health just as you would monitor a patient’s health. Use reports and graphs to stay up-to-date on outstanding payments and unpaid claims.
You need to know how to read an Aging Report to keep track of unpaid claims. This report will help you see which claims are likely to get paid—and which aren’t. If a claim is more than 90 days old, it has a 75 percent chance of going unpaid.
Once you review your aging report, adjust off any charges that you know you won't collect, whether the claim was correctly denied or the balance was applied to a deductible. Updating the report will allow you focus on the claims you need to follow up on.
Keep a Consistent Schedule
You should submit billing on a regular basis as part of your revenue cycle management. You should have consistent times that you spend on follow up, outstanding medical record request and appeals, or any other information that the insurance company requests.
Work as a Team
The billing team should meet with providers to discuss coding and charting. Providers should be in the know about what clinical information insurance companies require to pay claims. With everyone on the same page, you can avoid errors and reduce the amount of time spent on follow up.
If you are struggling to get a claim paid, one option is to include the patient. Patients can play an active role in the follow up or appeals processes for denied claims. Insurance companies may be more willing to work with a patient to resolve payment issues.
COLLECTING UNPAID CLAIMS
Unpaid claims, even those of smaller dollar amounts can make a big difference in your bottom line. It’s important your billing practices include plans to address these issues. To address unpaid claims, you should always:
Organize the unpaid claims by insurer so that when you call the insurer, you can discuss many patients at once instead of having to make separate phone calls.
Begin with the oldest claims and move backwards to ensure you meet payor deadlines.
Check for typographical errors
Follow up on time, every time. If an insurer tells you a claim will be reprocessed in 10-14 business days, follow up on the 14th day.
Review Follow-Up Practices
When following up with a payor, you should:
Review any previous claim notes, reference numbers, document control numbers, authorization numbers, and patient information before calling the insurance company
Provide facility, patient, and claim information
Ask questions about:
Scheduled payment date
Date the claim was received
The process date
Any missing claim information
Who you can speak to get the claim paid
Immediately supply any missing information such as prior authorization, medical records, facility information, coordination of benefits, etc.
Submit Medical Records
Many insurance companies are requesting medical records more frequently. Send these records with a copy of the insurance letter or a cover letter with important authorization numbers.
DOWNLOAD OUR MEDICAL RECORD KIT
Depending on the insurer, you may have to fax the records, send a hard copy by mail, or upload them to an online provider portal. No matter which system you use, keep a note of when you sent the medical records, any fax confirmation number, patient portal reference numbers, or tracking number on mailed records. When you follow up with the payor, you will need this if they tell you the records weren’t received.
Assess the Unpaid Claim
Your patient’s insurance company will include a denial code with each explanation of benefits (EOB) that will tell you why they are not going to pay the claim. If the claim needs to be corrected, make the adjustment and send it back stating that it is a corrected claim. Some insurance companies such as Anthem require that you also change the type of bill (TOB) when you submit a corrected claim.
Keep track of denial codes in a spreadsheet so you can identify any trends in denied claims. These are common reasons for claim denials:
Review Authorization and Policy Terms
If you are sure you have authorization for the denied service, compare the two authorization numbers; typos are a common cause for denials.
Coding issues. You may need to call the insurance company. Each insurer approves different Rev/CPT codes which should be outlined in their coding guidelines. If you use the wrong code, it will get denied. You may be able to get the correct code from the insurance representative, but it’s more likely that you’ll have to look back at previously approved claims to figure out which code that company prefers.
Charge exceeds maximum allowable. Check the verification of benefits to see if it includes a limit. You can always send these bills back for reprocessing if you believe they are made in error.
Non-covered service. Even if you received prior authorization, the insurance company may say the claim is not covered, especially if you are out-of-network. In this case, request that the claim be reprocessed, referencing the authorization number. If there was an authorization error, you may need to request a retro-authorization. Your final option is to submit an appeal letter.
APPEAL BEHAVIORAL HEALTH CLAIMS
The appeal process takes time but can be important in recovering revenue. To write an effective appeal letter, ensure you have all the information you need, including:
Understanding of the insurance company’s appeal process
Knowledge of the patient’s specific policy guidelines
Patient information, including:
Specific “internal” criteria from the insurance company on why the claim is denied (this may include more information than the denial explanation of benefits code)
You’ll use this information to draft your appeal letter.
Writing an Appeal Letter
At the top left corner of your letter, include the client’s name, policy ID number, claim number, and dates of service. You should also list your facility name, NPI and/or Tax ID number.
The body of the letter should be clear and concise. First, you should include the reason the claim was denied, using the denial reason code from the explanation of benefits and any other additional information that you gathered during follow up.
Next, use evidence-based reasons and ASAM criteria guidelines to show why the insurer should approve the claim and why the service was medically necessary. Briefly cover the patient’s history. Cite relevant legislation, regulations, or CPT coding terms to strengthen your case. If you have a prior authorization number, include that and any notes from previous conversations with the insurance company.
Attach any clinical notes to your letter and send the appeal using certified mail with a tracking number, fax or other means per the insurer's guidelines.
Following Up on Appeals
If you can track your appeal letter, you should follow up once you have received confirmation it has arrived. Call the insurance company to ensure the appeal is in review.
The average appeal letter takes 90 days to be reviewed. Follow up during this time and until the insurer has decided on an outcome. Once the payor makes a decision, you should receive a written notice with the final determination and, hopefully, a payment.
However, if your claim is denied again, you’ll need to request a second level appeal (external review).
Guidelines for submitting an external review can vary by state, but typically follow the Department of Health and Human Services' guidelines. You can find instructions on how to submit an external review on the denial letter you receive from the patient's insurance provider. You can also request a form directly from the Department of Health and Human Services' website.
FIND A BEHAVIORAL HEALTH BILLING PARTNER
An experienced third-party medical billing company will help you with all aspects of your revenue cycle, minimizing the number of unpaid claims and time you spend on administrative work.
The right partner for you:
Understands healthcare revenue trends, helping you offset decreasing reimbursement rates
Helps update and train your staff on changing codes or other polices
Provides outstanding customer service with a single point of contact and fast response times
Undergoes regular training to keep their knowledge as up-to-date as possible
Uses billing software that fits your needs
Offers regular analytics and financial reporting
Assists with verification of benefits, getting you the information you need quickly
Knows the coding requirements for each insurance company to insure you receive the highest possible reimbursement
Consistently follows up on all appeals and claims denials
In short, the right third-party billing company works as your partner and an extension of your billing team. Contact DataPro today to learn how they partner with behavioral health facilities to increase revenue and help patients receive the care they need.