The Jigsaw of Complex Coding and Documentation

Behavioral health billing stands out as a complex jigsaw puzzle, with intricate coding and documentation requirements due to the wide range of diagnoses, treatments, and individualized care plans that patients may require. For example, a patient suffering from depression might require a different approach than a patient dealing with an eating disorder. Revenue Cycle Management (RCM) providers must have a deep understanding of the various scenarios and applicable codes in order to accurately bill for the physician’s services. This level of detail is not always required in other medical specialties, which may have more standardized and straightforward billing requirements.

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Navigating Diverse Rules and Regulations

In the world of medical billing, providers often have to navigate the labyrinth of a diverse mix of payers, including commercial insurance, Medicaid, and Medicare. Each payer has its own unique rules, regulations, and billing requirements, making it challenging for providers to manage their own practices and keep up with the constantly evolving standards. For instance, one insurance company may cover group therapy sessions while another only covers individual sessions. This adds an additional layer of complexity compared to other specialties where payer requirements tend to be more uniform.

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Verifying Benefits with Precision

Determining a patient's insurance eligibility and benefits is another crucial part of behavioral health billing. Eligibility requires providers to verify the patient's insurance coverage, copayments, deductibles, and prior authorization requirements. For example, a patient may be eligible for 10 therapy sessions under their insurance plan, but any additional sessions require prior authorization. Missteps in this process, such as billing for session time beyond what an insurance covers without prior authorization can lead to claim denials, which can be difficult to correct.

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Solving High Denial Rates and Rejections

Behavioral health claims are more likely to be denied or rejected than other medical claims due to the complexity of coding and payer requirements. For example, a claim can be denied because a specific therapy session is considered experimental or not medically necessary by the payer. As we saw in last week’s post, a majority of denied claims are due to insurance eligibility according to Change Healthcare’s 2022 Revenue Cycle Denials Index. The additional labor required to resolve claim denials and rejections often results in delayed payments or lost revenue, which puts a strain on the financial health of the practice.

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Behavioral health billing presents unique challenges compared to other medical specialties, due to the intricate puzzle of coding, documentation, payer requirements, and eligibility verification. By partnering with an RCM vendor experienced in behavioral health billing, providers are better equipped to navigate the complexities of the industry and optimize their practice's financial performance.

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How pMD^® Can Help

Here at pMD^®, our mission is to streamline and optimize as many areas of the patient care episode and the revenue cycle as possible. Through our advanced, end-to-end practice management and revenue cycle solutions, we’re able to help practices consolidate vendors, reduce costs, streamline workflows, improve patient care and satisfaction, and collect your maximum reimbursement quicker.

Not sure what a vendor could do to improve your behavioral health billing? Contact pMD^® for a no-commitment financial impact analysis by our team of healthcare RCM experts free of charge!

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