In the summer of 2015, Mercy Hospital in Portland, Maine closed its substance abuse recovery center in Westbrook, in part because of low reimbursement rates for addiction services. Shortly after that, the Sanford Addiction Treatment Clinic in Maine announced that they were closing for similar reasons. With a growing opiate addiction in Maine, and around the country, the worry is that other providers may also close, as a result of not being able to collect fees for the services they provide.
Collecting on claims is well known for its difficulties, which begin with collecting the right (and necessary) information during intake and move though collecting co-pays from patients, performing timely billing for treatment services and closing out files appropriately. Skipping any of these steps can negatively affect your reimbursements.
But, there are things you can do to ensure steps aren’t skipped, you collect all of the necessary information and you follow up appropriately. Implementing a few checks and balances can help you see your denials decrease and, as a result, your profit margins increase.
Set pre-treatment standards and documentation
Many behavioral health centers start to lose money even before a patient sets foot into their facility. When a patient or family member calls to register them, most staff capture the insurance information, schedule their arrival, and advise other personnel of the person’s upcoming arrival.
They also check with the insurance company to see if the patient is covered. However, getting an approval of “medical necessity” is not a guarantee of eligibility or that you’ll get paid appropriately.
A significant number of patients whose claims are denied by their insurance provider were never eligible for benefits in the first place. As much as you want to help a patient with an addiction, your admin staff needs to be sure they are collecting the right information and pre-certifying (also known as pre-authorization) before the patient begins treatment.
Each insurance company has specific information collection requirements. Is your staff aware of them and reacting appropriately? Also, keep in mind that insurance companies can change their terms of coverage. Being sure your staff stay on top of these changes and that they are collecting the data necessary can reduce the number of denials you see.
Here are a few pre-certification tips that can save you time and headaches:
- Become familiar with the evidence-based clinical guidelines for addiction, to be sure you’re describing conditions and treatments appropriately.
- Ask the health plans for their guidelines.
- Submit legible, complete documentation clearly stating the reason for the requested service.
- Follow up with the health plan if it hasn’t responded in a timely manner. It’s ok to reach out.
As important as the pre-treatment processes is what occurs after the patient leaves your facility, as the majority of your revenue may not come in until after they’ve finished treatment.
Is your documentation correct and complete?
Poor treatment documentation impairs the revenue cycle and jeopardizes coding accuracy. With the implementation of ICD-10 comes the introduction of many more codes (there are now approximately 68,000) that your staff need to be aware of.
There are a number of common documentation mistakes that delay claims, cause denials and result in inaccurate payments. To avoid payment delays and denials, include the following in your charting closeout process:
- Clarify any potential patient demographic and/or insurance inaccuracies,
- Double check that the codes you’re using are correct,
- Include detailed notes and charting,
- Perform effective utilization review, and
- Complete proper claims adjudication on the back end.
Some best practices
Here are a few additional strategies to help improve the rate of return for your patient billing, regardless of where the patient is in the treatment process:
- Ensure your billing practices are well defined;
- Ensure that potential patients/their family and insurance companies, are aware of your legal and ethical obligations concerning co-payments and deductibles;
- Ensure your insurance claims are legally defensible by having quality utilization review to demonstrate medically necessary levels of care; and
- Have a strong policy and procedure that is carefully followed and documented, to analyze any claims of a financial need based waiver request.
Putting some of these standards and structures in place will decrease your processing errors, ultimately decreasing denials and improving your revenues. Contact Infinity Behavioral Health Services at 866-677-5264 for help with your billing practices, from start to finish.