top of page
  • Rachel Woodward

Maximizing Reimbursement: Tips for Behavioral Health Providers Facing Record Requests and Retroactive Terminations

Behavioral health providers may have noticed an increase in medical record requests from HCSC (Health Care Service Corporation) Blue Cross policies, Blue Cross policies that are based in Oklahoma, Illinois, Texas, and New Mexico. The record requests have led to delays in the processing of insurance claims, especially for those patients who received care out of their home state. In some cases, Anthem is requesting money back for retroactively terminated policies or even offsetting the funds from current claims.

We initially noticed this delay in August - There were hold-ups with authorizations, above average denial rates, and an increase in medical record requests, even on those claims with prior authorizations.

It has recently come to light that the bulk of the delays are stemming from an investigation into fraud, specifically fraud from individual and family plans purchased on the exchange in the above-mentioned states. As part of the ongoing investigation, Anthem has started to request medical records, and in some cases retroactively terminate policies and ask for money back on claims that have already been paid out.

This is specifically troubling to in-network providers who are subject to clawbacks and offsets. This is also primarily affecting in-network providers because most of these policies only allow out-of-state coverage to providers who are in-network with their local Blue Cross.

Although there is no way around the payment delays or requests for medical records, there are things your facility or practice can do to effectively minimize the impact that this may have on your revenue cycle. Below, we list a few best practices that you can implement today that will lead to better outcomes with Blue Cross and other commercial payers.


Verification of Benefit Best Practices:

  1. Get a copy of the client’s ID before you treat them. Make sure that the state on the driver’s license matches the issuing state of the insurance policy or ID card that the patient provided you.

  2. Use Availity or other payer portals to double and triple check the information you were provided is consistent.

  3. Confirm that the insurance policy is active and not in a grace period. If a policy is purchased through the exchange, the patient is given a 90-day grace period to bring their policy current. In the interim, the insurance company will continue to authorize treatmetn and pay claims. If the policy is not eventually brough current, the payer will request their money back from the start of the grace period.

  4. Ask the insurance representative if there is a set termination date on the policy and if the client pays month to month. If the patient is required to pay each month, ask them to provide you with a receipt after each payment to ensure that their policy remains in good standing throughout their entire length of treatment.

  5. Verify eligibility monthly – specifically for policies that are purchased through the exchange.  Because of the 90-day grace period, plans can retroactively terminate coverage, and you will be left without payment or trying to track down the client to reinstate their policy.

  6. Make sure the client has the policy for 90 days.  The insurance companies have started requiring their members to maintain the policy for 3 months from the date of activation.  Many people are getting the policies to go to treatment and then cancel the policies as soon as they discharge.  We have facilities that the entire stay has been clawed back after payments were received.  If clients come in with exchange policies that just became active, you need to make sure they are paid up for 90 days. 


Evaluate Your Census

What are your cash flow needs? If the success of your facility depends on a quick claims turnaround time, then you may want to consider the time it takes each payer to finalize and pay claims.  Certain payers and policies are notoriously quick or slow to pay, and understanding this can improve your overall cashflow. Not sure how to assess this?

When you treat a patient with problematic insurance policies, you are at an increased risk for a chart review. If you are required to send in the client’s chart for pre-payment review, you can expect the claims processing time to increase by a minimum of 30 business days.


Audit Your Medical Charting

Medical record requests are not only impacting Blue Cross HCSC policies but are becoming a common practice across all payers. Insurers want to make sure that the clients are receiving care that meets there guidelines, and that it is appropriately charted for. This includes but is not limited to timely signatures on treatment plans, objective goal setting, and individual and group therapy notes that are specific to the client’s specific goals.

As behavioral healthcare progresses, it is critical for providers to be informed of any changes or updates may impact their cash flow, and ultimately their ability to provide quality of care for their clients.

When running a facility, there are many factors to consider. If you have questions would like additional support, please contact us. We are always happy to help.

35 views0 comments


bottom of page