Billing and RCM for Behavioral Health Providers: The Essential Guide
How behavioral health providers can optimize billing
Establish systems to get reimbursed in full, on time, every time
Billing and RCM for behavioral health providers has is basically a complex accounting process, with many unusual details and quirks. In our experience, most behavioral health providers don’t fully understand what is required to navigate the billing and RCM process successfully, to get reimbursed fully for the services they provide.
Since many behavioral health providers are independent, billing and RCM take on additional urgency. At the same time, many behavioral health providers, and especially independent behavioral health professionals, lack the infrastructure required to ensure all claims get paid.
UNDERSTANDING THE STEPS OF RCM IN behavioral HEALTH SERVICES
Obtain referral from primary care provider
Determining medical necessity
Documenting and verifying medical necessity
Performing the tests
Waiting for claims to be paid
The Mindset of an Independent Business Owner
As an owner or partner in an independent behavioral health practice, billing and RCM are ultimately your responsibility. But of course, that doesn’t mean doing the work yourself. Rather, you need to assemble a team of skilled people on your team, whether in-house or an outside partner. It’s usually most efficient to establish a relationship with a medical billing company, preferably one that specializes in billing for behavioral health providers, or at least has substantial experience working with behavioral health billing.
This is because each specialty has its own unique challenges. While providers in many areas struggle to bridge the gap between the clinical and business aspects of their practice, in general, behavioral health providers may have more difficulties than most.
Regardless, in any practice, it is remarkably easy for practitioners to let billing & RCM get to a very bad state, and behavioral health is no exception.
The good news is that these issues are completely avoidable! The first step to fixing them is to make a decision that you will not continue losing money. Addressing this issue is very different from caring for patients. The business side of practice is quite different from the clinical side, especially in behavioral health.
Understand the Steps of RCM in Behavioral Health Care
In behavioral health, as in other areas of medicine, patient encounters follow a predetermined sequence, with each subsequent step dependent on those that come before it. Practitioners need to understand the significance of each step for billing and RCM, as well as from a clinical perspective.
STEP 1: OBTAIN REFERRAL FROM PRIMARY CARE PROVIDER
Most patients’ healthcare coverage is through an HMO. In these cases, their initial step will be to visit their primary care provider. If their PCP determines that they would benefit from seeing a behavioral health professional, they refer the patient to your team.
In the HMO scenario, referral from the primary care practitioner or the specialist is the first step of your billing process. Once you receive the referral, you share it with your biller, and they record and track it.
Remember, every step of the RCM process depends on what comes before it.
The referral hinges on the physician’s evaluation of medical necessity, and each patient visit requires both demonstration and documentation of medical necessity. If the patient’s insurer determines that the criteria for medical necessity are either not met, or not documented, that will usually be enough for them to deny the claim, and not pay for the test.
STEP 2: DETERMINING MEDICAL NECESSITY
In theory, it would seem like the “medical necessity” of care should be exclusively, or at least primarily, determined by the physician. In reality, however, the patient’s insurance company has an independent process for evaluating the medical necessity of each test.
Each insurer has its own specific definition of medical necessity, both in general and for specific procedures and courses of treatment. These definitions are somewhat different for different types of practitioners. In real life, you’ll never be able to keep track of all the minute changes. Rather, it’s your biller’s job to keep up with changing requirements, ideally in a proactive manner.
From the insurance company’s perspective, a claim of medical necessity usually rests on a number of different criteria, such as:
The patient having insurance for at least a minimum period of time
The patient experiencing their health issue for a minimum period of time
The patient’s health issue being the result of an underlying condition
The physician having attempted other interventions, which have not resolved the patient’s issue thus far
The above are some examples, and there may be others, depending on the specific course of treatment for each specific patient. In terms of demonstrating and documenting “medical necessity,” the key thing to understand is that the tests you perform must specifically fulfill all of the insurance company’s criteria for approving that specific test. On the insurance company’s side, an auditor, rather than a physician, is most likely responsible for making these evaluations of medical necessity, although physicians will certainly be involved in setting the parameters for such evaluations.
For a good a general overview of this topic, the American Association of Family Physicians has a good guide to the broader concept of medical necessity. Although published some time ago, it still covers the essential concepts very well, and while it doesn’t specifically address the subject in relation to behavioral health, it still conveys everything you need to know.
STEP 3: DOCUMENTING AND VERIFYING MEDICAL NECESSITY
If the patient’s insurance company reviews your notes, and for some reason determines that a certain course of care and treatment doesn’t meet their criteria for “medical necessity,” your claim will be rejected. Often, you will have already provided care, and incurred your expenses, before you learn the claim has been rejected.
One of the common reasons claims are rejected is due to issues or deficiencies in the clinical notes from the provider’s initial evaluation. Different insurance companies have different requirements for what information must be included in that note to demonstrate medical necessity. By itself, this might seem confusing. What’s more, insurers may change these requirements may change at any time.
In practical terms, it’s impossible for providers, or even the best billers, to keep up with changing requirements of individual insurance companies related to medical necessity the full range of possible services. Nevertheless, a robust billing process will ensure you get paid despite changing requirements.
You should work with your biller to ensure the following:
Use detailed and comprehensive, customized templates in your EHR notes, to ensure you include all required information and meet criteria of different insurers
If a claim is rejected, your biller should immediately contact the insurance company to determine the specific reason for the rejection
Your biller should ensure you make edits and updates to your clinical notes ASAP, so the claim can be rebilled
Once you understand the insurance company’s new requirements, should update the global template in your EHR to include any necessary information
In practice, you can update your notes and rebill each claim as many times as necessary. However, each rejection causes a delay in payment, and requires more work from you and your team, so you should strive for efficiency.
STEP 4: CARING FOR THE PATIENT
From a clinical perspective, it’s extremely important that billing issues don’t hinder you from providing appropriate care. From the time a patient is referred to you, you should be free to embark on a course of counseling as best suits the patient’s needs.
However, it must be noted that this involves a significant up-front investment in your time.
Your biller must ensure that the demands and urgency of your relationship with the patient is in no way hindered by issues of getting paid for your services. You should never find yourself seeing a patient while at the same time wondering whether you’ll be paid.
If the patient has appropriate insurance coverage, you should be able to proceed with full confidence that the billing process will be managed successfully. If for some reason the patient is not covered, you must be made aware of this in advance, so you can choose the best course of action.
STEP 5: WAITING FOR CLAIMS TO BE PAID
If your billing service is doing its job, you should receive payment within a predictable time frame.
What does this mean exactly?
As much as possible, you should try to quantify the effectiveness of your billing process. Some key reports to review include:
If your billing service is doing its job effectively, these numbers will reflect it.
The Role of an Effective Behavioral Health Billing Service
A skilled and diligent medical billing partner will dramatically reduce and often eliminate unpaid claims from insured patients.
As we mentioned, in our experience many behavioral health providers lack the internal infrastructure and processes to ensure they are reimbursed at the highest rate. For various reasons, including the fact that many behavioral health providers are solo practitioners, inadequate billing practices are probably more common in this field as opposed to some other areas of medicine.
What’s more, in this field, when patients may not have coverage, or may not fully understand their coverage, the provider’s humanitarian imperative to help them often overrides concerns about billing and insurance. While this is understandable, even noble, it’s not a sustainable business practice.
We always emphasize to our clients that behavioral health providers should not bear the financial burden of billing issues. Insurance providers exist for the purpose of paying health expenses. You should never have to wonder whether you’ll get paid, especially not due to internal billing issues.
If you have questions about your current billing situation, we offer a free, no-obligations revenue analysis to help you better understand your revenue and collections. Get in touch with us to learn more