5 Ways Your Behavioral Health Organization Can Stop Claims from Getting Denied

Submitting clean insurance claims is a crucial part of effective revenue cycle management. Want to do more to prevent payer denials? These are five actions your behavioral health organization can take today to stop claims from getting denied:

1. Educate Your Behavioral Health Staff on Preventing Claim Denials

If your staff education efforts conclude with the end of the onboarding process, you are missing vital opportunities to improve your team’s performance when it comes to preventing claim denials.

Conduct regularly scheduled in-service sessions to review key procedures and address any challenges that your behavioral health organization’s staff members have encountered with the claim submissions process. Be sure to invite representatives of every department who contributes to this process, such as members of your clinical and financial teams.

To make these sessions as meaningful as possible, incorporate internal audits into the claim submission process. This will help focus your team’s attention and ensure that you are providing relevant, actionable feedback on how to prevent denied claims. It is also an ideal opportunity to learn from past mistakes.

“I advise [behavioral health] organizations to do this on a quarterly basis at least,” said SimiTree Behavioral Health Business Development Executive Jeanna Boyer. “Don’t wait for problems to arise before you take action.”

2. Verify Your Behavioral Health Patients’ Information

When looking for simple ways to avoid claim denials, it is impossible to overstate the importance of verifying every new behavioral health patient’s insurance information before they begin to receive care.

If you haven’t confirmed all relevant data about your patient’s coverage, you risk significant delays in the payment process. In worst-case scenarios, you may not even be paid at all.

Also, remember that this isn’t simply a matter of confirming that the patient has insurance.

“Insurance verification isn’t just about the payer; it also includes the patient’s specific plan,” Boyer said. “For example, if the plan includes behavioral healthcare coverage, how does the provider define behavioral health? You have to ask the right questions.”

3. Know Your Behavioral Health Organization’s Payers

In addition to verifying all relevant details of your patients’ insurance policies, you should also be making a concerted, ongoing effort to get to know your behavioral health organization’s payers.

As Boyer previously advised, an important part of this effort is asking the right questions. For example:

  • Does the payer require a referral from a primary care physician?
  • Are prior authorizations required?
  • Do you need to send documentation to the payer so that they can confirm medical necessity?

Every payer has their own guidelines, processes, and expectations. It is your behavioral health organization team’s responsibility to be aware of these standards and to remain current on any changes. Don’t leave anything to chance. If you have thoroughly reviewed the patient’s policy and still have questions, contact the payer directly.

4. Document Your Behavioral Health Services

When it comes to documentation, it is important to be thorough, accurate, and consistent with each payer’s preferences.

Here are a few tips to keep in mind:

  • Make sure you are using the most current versions of the Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), and International Classification of Diseases (ICD-10).
  • Always code to the highest specificity. For example, if a patient has major depressive disorder, your coding should also indicate if their symptoms are mild, moderate, or severe (and, if severe, whether psychotic symptoms are also present).
  • Some payers prefer to have their codes bundled. Others want them separated. Verify your payers’ expectations before you submit.
  • Accuracy is essential. It is fraudulent to bill for misrepresented services, even if the misrepresentation is the result of a simple coding error.

Failing to properly code your patients’ behavioral health conditions and document your services can have a severe impact on your revenue cycle, Boyer cautioned.

“Correcting claims can add 30 to 60 days to the payment process. Continued mistakes can also open you up to payer reviews or payer audits,” she said. “If your payer conducts a pre-payment audit, this means that you will have to submit medical records on every claim before they will even look at them.”

5. Use Technology Appropriately

Technology can play a vital role in your efforts to prevent claim denials. But you need to make sure you’re using the right systems in the right ways.

Most behavioral health organizations use at least two types of technology to create their claims: a medical records system (either an EMR or an EHR) and a billing system. Make sure your systems are communicating with each other so that you don’t have to manually transfer data from your EMR or EHR into your billing software.

You also need to configure your billing software properly, which includes setting “scrubbers” that will review your claim and flag missing or incorrect information before you hit the send button.

“You want that claim to be as clean as possible the first time you submit it,” Boyer said.

One note of caution: Don’t let your reliance on technology strip away all hints of personalization. Using boilerplate, cut-and-paste language may shave a few minutes off the process, but it can also increase the likelihood that the claim will be denied.

“Don’t rely on templates,” Boyer said. “You can have guides, but you need to provide specific information for each patient.”

Struggling with Claim Denials?

SimiTree Behavioral Health offers customized guidance and support for all aspects of behavioral healthcare billing, including helping organizations avoid claim denials. Contact us today to speak with an expert.