Medical Billing For You

Medical billing for substance abuse and mental health facilities, or any other medical care is critical to the success of your practice. Medical billing is a complex process that is commonly overlooked. The key to success is a well-executed process that begins before you see a patient and does not end until every dollar you are owed is collected. There are steps throughout the process that will help ensure that your behavioral health facility or medical practice does not leave any money on the table.

If you are looking to maximize profits, use this guide to see how your behavioral health facility or medical practice can improve its processes for quicker and more accurate claims processing.

INTAKE ASSESSMENT FOR BEHAVIORAL HEALTH

During an intake assessment, you should gather all the information you need to actively manage a patient’s insurance billing during their care. These items are critical for the initial insurance billing and will also save you down the line if you need to appeal a claim with the client’s insurance company. A thorough intake assessment will also give you the information you need to obtain prior authorization and gives you the opportunity to inform the patient of their financial responsibilities. It’s the critical first step to an efficient billing process.

Intake Best Practices

1. Make a copy of the patient’s ID and insurance card.

2. Get an up-to-date address and phone number.

3. Collect deductible and admission fees.

4. Explain liability to the patient which includes co-insurance and copay. Then, set up a detailed payment plan so that the patient is not surprised when they receive a bill.

Clients should sign the following forms:

• Release of Information (you will need this to dispute OON denials)

• 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 (AOR form)

• Parent/Guardian Signature (minor only)

DETERMINE MEDICAL NECESSITY

Before you request authorization from an insurance company, you need to understand how the insurer determines medical necessity. Each payer may have slightly different guidelines but the safe bet is to use ASAM criteria for substance abuse, and LOCUS guidelines for mental health.

This is important because if you begin treating a patient for the incorrect level of care, you risk the services not being covered by the insurer, therefore, losing out on revenue. It is important that your clinicians know how to properly assess using ASAM or LOCUS guidelines. This will help you with medical necessity appeals down the line.

Your UR specialist should also use ASAM or LOCUS criteria to communicate with insurers. They are the most widely used and comprehensive guidelines for placement and continued to stay for patients with addiction and mental health disorders. With a complete understanding of these guidelines, you have the best chance of reaching a quick agreement with the insurer about what level of care the client should be placed in. This is yet another step that will contribute to a seamless billing process.

OBTAIN AUTHORIZATION

Almost all facility billing requires prior authorization from the insurance company if you expect to be paid. Best practices for prior authorization include:

• Call the insurer within 24 hours of admission.

• Refer to the documents that you received during the intake assessment.

• Use ASAM or LOCUS level of care guidelines.

• Stay organized - Keep a separate file for each patient that includes critical information you received from the facility or the case manager as well as their prior authorization number.

• Take notes while you are on the call with the case manager, documenting any information that you need to relay to the treatment team at the facility.

• Always document the representative’s name, the date of the call, and the call reference number.

• Monitor your patient’s policy to ensure it's active. If a policy lapses while they are under your care, the services will no longer be covered.

Revenue Cycle Management

Your revenue cycle begins the moment a patient is admitted for care and doesn’t end until you’ve received payment for all their services. Proper revenue cycle management leads to faster payment and fewer unpaid or denied claims. If you follow the protocols listed below, you can count on quick and seamless insurance reimbursement.

Accurate Patient Information

This may seem obvious but even the smallest typo in a patient’s name will delay payment. Before a patient admits, you should have the following information:

1. Patient demographics: name, address, birthday (get a copy of their driver’s license)

2. Primary and secondary insurance information (get a copy of the card)

3. Any co-pays or deductible that the patient is responsible

Sometimes a patient’s insurance policy will terminate 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 to verify that the policy remains active throughout the patient’s stay.

Monitor Claims Reports

Continually monitor your company’s financial health. Use reports stay up to date on outstanding and unpaid claims. Review your outstanding A/R monthly. Most of your claims should be under 60 days old. Anything over 60 days should already be in appeal or followed up on. If you know that you will not collect on a claim, write it off. Keeping your report up to date will allow you to focus on the claims you need to follow up on.

Keep a Consistent Schedule

You should submit billing on a regular basis to keep your cash flow consistent. Set specific times for billing, follow-up, medical records review and appeals. Because there are so many moving pieces, it is important to allocate time for it all.

COLLECT 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 on a claim-by-claim basis, but also as a whole. The most effective way to do this is to categorize unpaid claims by denial reason. If you recognize a denial pattern, you can address the specific issue on an organizational basis. For example, if you receive multiple denials for incorrect patient demographics, you know that you need to review intake protocols with your admission staff. Rather than fixing one claim at a time, which you will do regardless, this helps target and correct the larger issue moving forward.

Another best practice for collecting old receivables is to begin with the oldest claims and move backwards to ensure you meet payor deadlines.

Medical Records

Insurance companies are requesting medical records more frequently, even if you have a valid authorization. Unfortunately, there isn’t a way around this. 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 and any confirmation or tracking number. This information will save you if the insurer tells you that they don’t have the records.

INSURANCE APPEALS

The appeal process takes time but is critical to recovering revenue. To write an effective appeal letter, you need the following information:

• Understanding of the insurance company’s appeal process

• Patient information including the diagnosis, treatment plan, authorization number, clinical notes or correspondence from the insurance company on why the claim is denied

• Thorough notes and call reference numbers from previous interactions with the insurer regarding the claim you are disputing

The body of the letter should be clear and concise. You should include the reason the claim was denied along with evidence-based reasons and ASAM criteria guidelines to show why the claim should be paid. If the claim was authorized, include the authorization number. If other claims under that authorization number, reference it.

You may also want to briefly cover the patient’s history and cite relevant legislation or regulations to strengthen your case. Also include any notes from previous conversations with the insurance company and the reference number from the call. Attach any relevant clinical documentation to your letter. Once you submit the appeal follow up with the insurance company to make sure the appeal was received and put into processing.

BEHAVIORAL HEALTH BILLING PARTNER

An experienced third-party medical billing company will help you with all aspects of your revenue cycle. The right partner will:

• Understand healthcare revenue trends and appeal accordingly

• They will update and train your staff on changing insurance regulation or policies

• Provide outstanding customer service with fast response times

• Undergo regular training to keep their knowledge current

• Use billing software that offers analytics and financial reporting

• Know coding requirements for each insurance company to ensure you receive the highest possible reimbursement

• Consistently follow up on claims denials and appeal all open claims

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.