Addiction to alcohol, opioids, and substance abuse require comprehensive treatment and care. Most drug & alcohol treatment centers provide effective residential treatment programs, drug and alcohol detox and inpatient treatments, based on patient evaluation, physical health and well-being. Treatment methods may also include therapy, drugs, meditation and more. Most residential substance abuse programs helps promoting collaboration and incorporating the life skills.

Most standard health insurance plans will provide coverage for some form of addiction treatment. Behavioral medicine billing requires expertise in different areas – verification of benefits and eligibility, billing, and collections. Unlike other specialties, medical billing for behavioral & mental health especially substance abuse, is complicated mainly due to the type of care offered to patients and the coverage provided and rapidly changing industry laws and regulations. Certain plans cover medical detox, long-term residential treatment care, inpatient hospital detoxification, outpatient detoxification, inpatient rehabilitation, outpatient alcohol and drug abuse rehabilitation, dual-diagnosis treatment and aftercare counseling or therapy, while others do not. Both Medicaid and Medicare provide some level of coverage for substance use disorder. While Medicare A covers the inpatient services during a hospital stay, Medicare B coverage provides assistance with outpatient care, and prescription drugs are covered by Medicare D.

According to Advanced Data Systems Corporation (ADSC), drug rehabilitation treatment centers across the United States are struggling with cash flow issues as denial rates increase leaving patients with the burden of rising financial responsibility amounts. Addiction treatment centers are typically leaving 20-30% of their earned revenue unearned. ADSC highlights the key performance indicators (KPIs) that treatment centers should monitor to ensure consistency in collections.

  • Bill Charge Lag Times
  • Clean Claim Rates
  • Days Revenue Outstanding (DRO)
  • Accounts Receivable- Aging(A/R)
  • A/R over 60/90 Days
  • Denial Tracking
  • Payment Waterfall metrics
  • Revenue Actualization %
  • Referral Trending

Treatment duration or length of the treatment is one of the key factors that insurance carriers consider. While some carriers cover the entire length of the treatment, other plans will only cover a few days. Providers have to ensure that their patient’s health plan lists addiction treatment as a covered benefit and what their specific insurance covers. This is where insurance verification comes in. Earlier, services for the prevention and treatment for substance use disorders were not covered under mental health and general health care services.

Most claims get denied because the patient isn’t eligible for the services provided or the patient information doesn’t match the insurer’s information.

Other common causes of mental health claim denials are:

  • Failing to complete prior authorization before the treatment
  • Documentation errors such as not including timesheets or encounter notes
  • Not documenting the medical necessity of the procedures/treatment
  • Poor coding accuracy or not using appropriate medical codes
  • Typical policy violations in billing for behavioral/mental health treatments
  • Not recording progress notes promptly

Behavioral medicine medical billing services provided by reliable companies include insurance verification and authorizations that help physician practices avoid claim denials and delayed payments.

ICD-10 has thousands of billing codes pertaining to substance abuse and behavioral health treatment.

Behavioral & Mental Health Billing – Best Practices

Whether you are doing the billing in-house or outsourcing it to a medical billing and coding company, make sure that the medical billers & coders are trained well in the current standards to ensure clean claims. Coders should know the latest ICD, CPT and HCPCS codes for behavioral & mental health. To receive reimbursement for every level of care offered, it is important for behavior & mental health facilities to implement accurate insurance verification process.

Best practices to consider include

  • Collect maximum details from the patient – alternate phone numbers, addresses, insurance type, and social security number before calling an insurance company
  • Always verify eligibility and benefits not only for new patients, but also for hospital admissions, on the Date of Service (DOS) and for a follow-up
  • Regularly track submitted claims to identify and resolve any issues for denials without exceeding the time limit
  • Have a clear understanding of the usage of new Health Behavior Assessment and Intervention (HBAI) Current Procedural Terminology (CPT) Codes while billing for mental health services
  • Have a strong prior authorization team to ensure all the benefit verification is done well before the patient’s office visit

An experienced medical billing company provides the service of trained behavior & mental health billers, coders and insurance verification specialists. Many providers are also investing in medical eligibility verification software, which allows their staff to instantly check medical eligibility and avoid reimbursement issues.