For behavioral healthcare providers, efficient interactions with payers are essential components of successful revenue cycle management. From your initial contact with a new patient until the day you are paid for the services they received, here are four tips for streamlining the insurance process:

1. Gather the Right Insurance Information

The insurance process should begin before your patient begins to receive care at your facility. Prior to intake, you should accomplish the following:

• Scan or copy your patient’s insurance card and any other relevant documentation.
• Reach out to your patient’s insurance company to verify that the information they provided is accurate and complete.
• Validate the scope of your patient’s insurance benefits, including coverage limits, copays, and if the benefits are carved out to another carrier for claims submission.
• Confirm the payer’s policies and expectations regarding matters such as prior authorizations and submission timelines.

While speaking with a representative from your patient’s insurance company, you should also discuss their electronic submission requirements. Taking a moment early in the process to ensure that your coding aligns with the payer’s system can save you a considerable amount of time (and help you avoid unnecessary frustration) when you submit your insurance claims.

2. Provide Thorough Documentation for Insurance Providers

When preparing to submit an insurance claim, it is important to keep these key concepts in mind:

• Documentation: It is difficult to overstate the importance of documenting appropriately. In addition to providing detailed descriptions of the care your patient has been receiving at your facility, you should also have their intake assessment, as well as any files you receive from the referring professional or any other prior treatment providers.
• Justification: When preparing the documentation, remember that simply describing what services the patient received may not be enough. You should also address why the patient’s treatment team chose to provide these services. Payers want to see evidence of the thought processes and justifications behind your team’s clinical decisions.
• Personalization: Given the tremendous workloads that clinicians and other facility-level personnel are dealing with, it can be tempting to use templates or other shortcuts when preparing documentation to accompany claims. Resist this temptation. Payers want to know that your team is focused on meeting the unique needs of the patient whose care they are funding.
• Preparation: Effective discharge planning can be vital for a patient’s continued progress. It can also be essential for a successful claim adjudication. Think about how you can demonstrate that you are preparing your patient for sustained success. If the clinical team anticipates referring the patient to a step-down program or a community-based service, include that information in your documentation.

Finally, don’t overlook the importance of timeliness throughout the insurance process. Know when the payer expects to receive your claims, and make sure you always meet their deadlines.

3. Respond Promptly to Claim Denials or Rejections

To most people, rejections and denials are usually the same thing. In the insurance world, there are important distinctions between these two terms.

• Rejections occur prior to a claim being processed by the payer. If you receive notice that a claim was rejected, this means that your submission contained incorrect or incomplete information. You may want to begin by double-checking your patient’s information to make sure that details such as their insurance ID number are correct. Once you’ve verified this information, confirm that the services you are billing for have been accurately coded.
• Denials indicate that the payer received your submission, reviewed your claim, and ruled that it is unpayable. When you receive a denial notice, your first step should be to review the EOB (explanation of benefits) to determine the reason that the claim was denied. Claims may be denied for a wide range of reasons, including that you failed to secure prior authorization, the patient’s policy doesn’t cover the service, or the payer determined that the service was not necessary. Denied claims can be appealed, though this process may vary from payer to payer.

Rejections and denials share one important similarity: They both require prompt responses to prevent aging claims and prohibitively large patient balances.

4. Automate Your Transactions

Electronic remittance advice (ERA) is the key to a streamlined insurance process.

As highlighted by the U.S. Centers for Medicare and Medicaid Services, ERA transactions include a wealth of payment-related information, including reasons for adjustments due to factors such as:

• Contract agreements
• Secondary health plans
• Patient benefit coverage
• Expected copays and coinsurance
• Capitation payments

To facilitate the timely transfer of funds and eliminate the need to wait on paper checks, make sure that your behavioral health organization is set up for EFT or direct deposit. Each insurer is different, so it’s important to know if the insurer uses a third-party system, such as Availity, PaySpan, InstaMed, or EchoHealth, or if there is another payment automation service that your payer uses.

Need Help with the Behavioral Health Insurance Process?

SimiTree Behavioral Health offers customized guidance and support for all aspects of behavioral healthcare operations, including assistance with the behavioral health insurance process.  If you want to be sure that your organization is operating at maximum efficiency, contact us today to schedule a complimentary consultation.