What is the Difference between Insurance Verification and Insurance Authorization?

What is the Difference between Insurance Verification and Insurance Authorization?

Revenue cycle management (RCM) is the administration of financial transactions that result from the medical encounters between a patient and a provider, facility, and/or supplier, according to the Healthcare Business Management Association (HBMA). RCM involves several processes from the time a patient schedules an appointment to claim submission and payment collection. Insurance verification and authorization are key processes performed in the initial phase of RCM or medical billing insurance claims process. Though both aim at preventing claim rejection and delays, insurance verification and prior authorization are distinct and different.

What is Insurance Verification?

The life cycle of a patient begins with appointment scheduling and registration where demographic and insurance information are collected. This sets the stage for insurance verification – the process of checking the patient’s health payer coverage and benefits prior to the encounter. The goal is to confirm:

  • If the patient has active insurance coverage
  • What procedures/services are and are not covered
  • How much of each procedure the insurer will cover and the patient’s financial obligation

The following information is collected when a patient calls to schedule an appointment:

  • Patient’s name and date of birth;
  • Name of the insurance provider
  • Name of the primary insurance plan holder and their relationship to the patient;
  • Patient’s policy number and group ID number (if applicable); and
  • Insurance company’s phone number and address

A reliable insurance verification service provider will make sure that all the required details about insurance eligibility and benefits are collected before the patient visit, which includes:

  • Type of plan and coverage details
  • Calendar year/ policy year
  • Effective date
  • Plan annual maximum
  • Plan deductible
  • Primary and secondary insurance
  • Per code coverage, if available
  • Copays and deductibles
  • DME coverage
  • Plan exclusions
  • Referral and pre-authorization requirements
  • Out of network benefits

Insurance verification specialists will get a full breakdown of patients’ insurance coverage and benefits by visiting payer web portals or calling the insurance carrier with the information collected from the patient during the initial phone call.

Proactive patient eligibility verification is crucial for a successful claim submission in medical billing:

  • Improves the patient experience: Verifying the patient’s insurance before the office encounter and communicating to them as to what their plan covers and doesn’t cover will ensure transparency. Patients will know about the costs of their care and can better prepare to pay their bills. With transparency throughout the medical billing process, patients will not face any costly surprises.
  • Reduces claim denials: If the patient’s information is outdated and the provider uses that to submit a claim, it would result in an instant payment denial. Verifying patient eligibility upfront will ensure that claims are submitted with current and accurate data and prompt payment. Insurance verification services minimize claim denials and saves time and money that would go into reworking claims.
  • Maximizes cash flow: Proper insurance verification will ensure that claims are submitted with up-to-date information. Clean claims will be approved faster and speed up the medical billing cycle. Reduced denials and a larger number of clean claims will increase practice cash flow.

What is Insurance Authorization?

Insurance authorization or prior authorization is a “health plan cost-control process by which physicians and other health care providers must obtain advance approval from a health plan before a specific service is delivered to the patient to qualify for payment coverage” (American Medical Association). Prior authorization is also referred to as precertification, pre-authorization, prior approval, and predetermination. Insurance companies use the prior authorization process to determine if a prescribed medical treatments, drugs, or medical equipment will be covered in full or in part.

The insurance authorization process begins when a service prescribed by a patient’s physician is not covered by their health insurance plan. The physician’s office has to communicate with the insurance company and complete a prior authorization form along with documentation supporting the medical necessity of the specific procedure, test, medication, or device. Prior authorization is a time-consuming process that can delay patient access to care.

Insurance Verification vs. Insurance Authorization

The differences between insurance verification and insurance authorization are as follows:

  • Unlike insurance verification which is performed before the patient encounter, the prior authorization process begins when a procedure, test, medication or device that the physician prescribes for a patient requires preapproval from the insurer.
  • Insurance verification is related to the process of creating and filing medical claims and obtaining payment for patient services, while prior authorization is about obtaining prior authorization for services.
  • For a smooth preauthorization process, medical billing personnel need to be knowledgeable about the CPT code for the services for which approval is requested. Insurance verification focuses on coverage status, active/inactive status and eligibility status.

Both insurance verification and authorization are time consuming processes that can lead to denials. That’s why they are best handled by experts. Outsourcing these tasks to an experienced insurance verification company can go a long way toward saving time, preventing denials and delays, optimizing reimbursement, and improving patient care and satisfaction.

What are the Different Types of Denials in Medical Billing?

What are the Different Types of Denials in Medical Billing?

Earning sufficient revenue to cover overhead expenses and provide quality care is a major challenge for healthcare practices and hospitals. In addition to numerous declining reimbursements, government regulations, and third-party requirements, medical billing denials are the main concern for sustaining a successful medical business. Denials and delayed or incorrect reimbursements from payers are the results of inefficient coding and billing. Getting professional support is a viable solution. There are different types of denials and partnering with an experienced physician billing company can help prevent them.

Change Healthcare: Most Medical Billing Denials are Preventable

Findings of the Change Healthcare 2020 Revenue Cycle Denials Index show that about 85% of denials are preventable, but nearly a quarter (24%) of these cannot be recovered. The analysis revealed worrying statistics:

  • The average denials rate is up 23% since 2016, topping 11.1% of claims denied upon initial submission through the third quarter of 2020
  • Since the onset of COVID-19, denials have risen 11% nationally.
  • The highest denial rates are in regions with the highest first-wave of COVID-19 outbreaks
  • Half of the denials are caused by front-end revenue cycle issues (Registration/Eligibility, Authorization, Service Not Covered).
  • The top denials cause remained constant since 2016: Registration/ Eligibility, approaching 27% of denials.

Common Causes of Medical Billing Denials

Claim denials come under two categories: hard and soft. A hard denial is when the insurance refuses to pay the claim because the service is not covered. Even appeals may fail to reverse or correct a hard denial, leading to lost revenue. Soft denial is when an insurance company reviews a claim and rejects payment due to an issue like missing data or lack of documentation. Soft denials are temporary and have the potential to be revered if the provider makes the necessary corrections on the claim or provides the required information. Physician billing companies are well aware of the reasons for claims denials and help practices implement proactive strategies to prevent them.

  • Missing or invalid claims information: A denial can be triggered when a claim form is incomplete. Missing or wrong data on a claim could be everything from social security numbers to plan codes, modifiers, addresses, and other demographic and technical errors. The Change Healthcare 2020 study found that missing or invalid claim data accounted for 17.2% of medical billing denials and 26.6% are caused by patient registration/eligibility issues. Insurance verification plays a key role in preventing eligibility denials in medical billing.
  • Medical coding errors: Coding issues in the bill will result in a payment denial. Errors include: missing codes, wrong codes, using the wrong coding system for the insurer, standard of care does not align with the included diagnosis codes, or undercoding and overcoding which occurs when the claim contains higher-level CPT or HCPCS codes than what is supported by medical necessity, medical facts, or the provider’s documentation.
  • Duplicate claim or service: This type of denial occurs when claims are resubmitted for a single encounter on the same date by the same health care provider for the same beneficiary for the same service. Duplicates account for up to 32% of Medicare Part B claim denials.
  • Lack of coordination of patient benefits: Some patients may have multiple payers. Claims must be submitted to the primary insurance first, and depending on the need, the balance is submitted to the patient’s secondary and tertiary insurances. Reasons why coordination of benefit denial occurs include:
    • Estimate of benefits is missing
    • Another insurance is considered primary
    • The member has not updated additional insurance information

Coordination of benefits is necessary to determine which payer is the primary, secondary, and tertiary insurance to ensure that the correct payer’s pay and duplication of payments is prevented.

  • Service not covered: This type of denial occurs due to neglecting to perform insurance verification to determine if the procedures and services being provided are covered under the patient’s current benefit plan. Service Not Covered accounts for 57.7% of claims denials, according to the Change Healthcare 2020 Revenue Cycle Denials Index.
  • Medical necessity: A top denial reason (accounting for 6% according to Change Healthcare), medical necessity denials are hard denials. The reasons for this type of denial are:
    • Inpatient criteria have not been met
    • Inappropriate use of the emergency room
    • Length of stay
    • Inappropriate level of care

Medical necessity denials need an appeal to request reconsideration

  • Service already adjudicated: This type of denial occurs when a service is already included in another claim/payment which was already settled.
  • Authorization/Pre-Certification: Payers have specific prior authorization requirements and when these are not met, claims are denied. Moreover, these rules tend to change frequently and unexpectedly and practices would have to resubmit forms for denied claims in accordance with the payer’s updated specifications.
  • Time limit for filing has expired: Insurance companies have strict time limits for claim submission, including a deadline to submit reworked claims and reviews to check codes and coverage. Inpatient medical coding errors accounted for 81% of complex claim denials in the fourth quarter of 2015, and correcting them can cause delays that go past the submission deadline (https://itechdata.ai/).

Strategies to Prevent Claim Denials

Though most medical billing denials are preventable, the problem continues unabated. Medical Economics reported on a study that identified the factors responsible for the rise in claim denials as “a lack of denials resources, such as expertise to support appeals and data for root cause analysis, as well as staff attrition and training, growing denials backlog, and legacy technology”.

Implementing a denials-prevention strategy that includes the following can help reduce the risk of claim denials:

  • Know the types of denials your practice is receiving
  • Track denials – identify the source and root cause of denials
  • Monitor clean claims ratio
  • Prioritize medical billing and coding oversight
  • Determine what remedial measures to take and where they will have the greatest impact
  • Choose end-to-end revenue cycle management software
  • Utilize advanced analytics and artificial intelligence

Last but not least, choose the right partner – a reliable physician billing service provider that will provide dedicated support to manage your revenue cycle. An expert will work with you to identify problematic trends in denials and reduce your denials by implementing best practices for medical billing, coding, and insurance verification and authorization.

Insurance Authorization Crucial To Avoid Radiology Claims Denials

Insurance Authorization Crucial To Avoid Radiology Claims Denials

Medical imaging is an essential element in modern medicine. Medical imaging technology continues to advance and radiologists have effective screening tools to detect potential health disorders or conditions, enabling patients to get proper and timely clinical care. However, one problem that continues to trouble radiology practitioners is claims denials due to patient eligibility errors. Using insurance eligibility verification services is the best way to overcome this problem.

Medicare and commercial insurance companies will reimburse radiology services only if claims contain accurate information about the patient’s eligibility for coverage.  The key to avoiding radiology claims denials is to obtain accurate information about the patient’s eligibility for the service before it is rendered. Health insurance eligibility verification at the time of patient registration should focus on obtaining information about the following:

  • Insurance plan information: This involves verifying the following for each patient:
    • – Co-pays


    • – Co-insurances


    • – Claims mailing address


    • – Deductibles


    • – Patient policy status


    • – Effective date


    • – Payable benefits


    • – Plan exclusions


    • – Health insurance caps


    • – Type of plan and coverage details


    • – Referrals and pre-authorizations


    – Out of network benefits

It’s important to verify if the patient has secondary or supplemental coverage, which could be a vision plan, dental plan, or an accidental injury plan. Secondary health insurance can be also available directly to the patient or through a spouse’s medical plan. Primary and secondary plans work together to offer coordinated benefits to the member.

  • Demographic details: Getting the patient’s demographic information is essential for successful claims. Specific details that need to be collected are Patient name and ID#, gender, date of birth, Social Security Number, contact number, marital status, email address, residential address, and current employer. This information should be verified at the encounter.
  • Site of service: Radiology services are provided in different settings such as an imaging center, the outpatient department of a hospital, and physician’s offices. The level of co-insurance payment would be different for these facilities.  Site-of-service differences especially matter if the radiology practice has a capitated insurance contract, a health care plan that pays a flat fee for each patient it covers. This fee will be different for different sites of service. Proper coding is essential to prevent loss of reimbursement under capitated insurance contracts.
  • Prior authorization: Most insurance companies have specific prior authorization requirements for costly procedures including radiation oncology and high-tech imaging such as CT, CTA, MRI, MRA, MRS, Nuclear Cardiac, PET and CPT. Obtaining prior authorization before providing these services is essential to prevent claim denials for them. There are state regulations on who can obtain pre-authorizations – the radiologist or the ordering physician.

Obtaining radiology prior authorizations start with verifying patient coverage.  The practice staff must also collect all information relating to the patient’s condition and the reasons for the exam. Imaging orders must be appropriate and complete. Once these details are obtained, the radiology department or imaging center staff can contact the referring physician’s office to see whether the referring office has obtained authorization from the insurance company.

Outsourcing the prior authorization process can save time and ensure an efficient, hassle-free process. A professional radiology authorization company would have a dedicated team that is knowledgeable about the following:

    • – which plans require prior authorizations


    • – Which procedures in each plan require authorization


    • – Policy numbers that require specific types of authorization


    – How to obtain the authorization by calling the payer or contacting them through their website

Medicare and Medicaid have unique requirements for prior authorization. Medicare Advantage plans that commercial companies offer are different from standard Medicare coverage and have different submission requirements. Experts would be familiar with these rules and also up to date on payers’ changing rules and procedures related to prior authorization.

A radiologist-backed effort to rein in the onerous prior authorization requirements gained steam last year. Radiology Business reported that the aim of the bill is to increase oversight and transparency, reduce paperwork and delays, and streamline and standardize how Medicare Advantage plans use prior authorization. Among other proposals, plans would also be required to report their use of prior authorization and rate of denials.

As the insurance verification and pre-authorization process can be very time-consuming, and requires constant follow-up, radiology offices can benefit from partnering with an experienced radiology insurance verification company

How Do Insurance Verification Services Ensure Accurate Documentation Payers Are Looking For?

How Do Insurance Verification Services Ensure Accurate Documentation Payers Are Looking For?

Getting medical claims approved by payers is one of the most daunting tasks faced by healthcare practices. Submitting clean, accurate claims to payers requires practices to ensure clinical documentation with the correct diagnosis and procedure codes and documentation proving medical necessity. Importantly, medical practices also need to have comprehensive preauthorization and insurance verification services in place to determine patient coverage and benefits under their insurance plan.

What Payers Look for in Claims

The two main things payers look for in claims are compliance with payer eligibility requirements and good clinical documentation.

  • Compliance with Payer Eligibility Requirements

Eligibility problems are one of the main reasons for claims denial. Millions of claims are denied because eligibility has expired or the patient or service was not covered by the plan in question. According to a Kaiser Family Foundation (KFF) study, in 2019 18% of plan-reported denied claims were denied because the service was not a covered service and 9% of plan-reported denials were because the claim lacked a required referral or preauthorization.

Certain conditions have to be met in order for an individual or group to be considered eligible for insurance coverage. When they adjudicate claims, payers look for documentation that provides evidence of the patient’s eligibility for benefits.

Payers will also check if prior authorization requirements have been met. Payers require prior authorization certain drugs, treatments, tests, and other medical services on the grounds that it promotes patient safety and guideline adherence, and helps controls healthcare expenditure. When they authorize a service before the patient encounter, payers assign an authorization number that the medical billing service provider should include on the claim submitted for payment.

In addition to checking whether the service is authorized, the insurance company will also assess claims to find answers to questions relating to the patient’s coverage, such as:

  • Is the patient a member of a plan?
  • Is the coverage valid – what is the effective date of the policy
  • Is the particular service covered by the benefits of that plan
  • Is the provider a member of the plan network?
  • Has the patient met his or her deductible?

How Insurance Verification Services Help

Practices need to have a robust patient eligibility verification process in place. Insurance verification involves checking the patient’s insurance coverage and benefits prior to date of service to ensure payment for services. Outsourcing this task is the best option to free front office staff of this cumbersome but necessary process.

  • Insurance verification and authorization companies are dedicated to preventing denials that can occur due to eligibility problems. With proper verification, providers can check whether the patient’s insurance is active, premiums are paid, services are covered and deductibles are met, well before providing treatments.
    • Insurance verification specialists will verify details such as: demographic data, name and date of birth of the primary insured, social security number, ID number, group number, claims mailing address, plan exclusion, DME reimbursement, primary and secondary coverage, policy limitations, insurance carrier and their contact information, co-payments, co-insurance, and deductibles. After verifying these details the insurance verification service provider will inform the payer that the patient is eligible for the services. This information will provide the foundation for a successful claim
    • Insurance authorization service will involve obtaining authorization for certain medical treatments that need to be approved or pre-certified prior to being provided.
    • The company will also follow up with the patient as needed to obtain any additional information required to process the claim. Patients will be informed about their financial responsibility or out-of-pocket costs.
    • After the medical record and billing system are updated with all the necessary information, the insurance verification company will send the claim to payer.
  • Good Clinical DocumentationInadequate or missing documentation is a major reason for many claims denials. Claims and associated medical records are reviewed for compliance with payer coverage, coding, and billing rules. The documentation should include:
    • A definitive diagnosis and support severity with the correct ICD-10 codes.
    • The plan of care based on the reported diagnosis as well as the goal of the plan and when the patient can expect to reach the goal

The documentation should be adequate to support the claims as billed. It should provide evidence that the allowed services were medically necessary and actually provided at the level billed. Documentation is examined see whether they meet payer guidelines relating to medical necessity, preadmission rules, requirements for therapy, formulary and nonformulary medicines, and other payer specific requirements.

When the medical documentation submitted along with the claim is inadequate to support payment for the services billed, the claim is considered as having “insufficient documentation” errors. Other examples of clinical documentation errors include: missing physician signature on an order, incomplete forms and progress notes, unauthenticated medical records, and no documentation of intent to order services and procedures. It is the responsibility of the physician to ensure good documentation and report medical services using the right ICD-10 and CPT codes.

Medicare’s national and local coverage determinations lay down the standards that must be followed to attain a benefit category and reimbursement. Likewise all commercial insurance companies have their own guidelines based on the contract. Insurance verification and authorization companies are knowledgeable about these rules and can help practices ensure accurate claims submission and prevent denials.

Prior Authorizations – Current Challenges and Solutions

Prior Authorizations – Current Challenges and Solutions

Health insurance carriers require prior authorization (PA) as a condition of payment for many services. Payers use PA to determine if certain medications, products, treatments or services are medically necessary before they are prescribed/rendered to beneficiaries. However, the PA process poses an administrative burden for physicians’ offices and managed care organizations, and affect patients by delaying needed care. Many providers rely on insurance authorization companies to make the process as efficient as possible. In fact, such support is extremely significant now as payers are demanding prior authorization for patient care even as the COVID-19 pandemic continues, according to a recent health leaders report. Though some payers had relaxed their PA requirements in response to the COVID-19 pandemic, many resumed their PA policies as the pandemic wore on.

New AMA Survey reveals Prevailing Prior Authorization Issues

In a new survey by the American Medical Association (AMA), 94% of physicians reported that PA demands caused care delays, and 79% said patients abandoned treatment because of authorization issues with insurers. The survey was conducted in Dec 2020 and covered 1000 practicing physicians. The other key findings of the report are as follows:

  • 90% of physicians said that PA programs have a negative impact on patient clinical outcomes
  • 30% reported that PA requirements led to serious adverse events for patients in their care
  • 85% said the burdens associated with PA were high or extremely high
  • Only 15% of physicians reported that PA criteria were often or always based on evidence-based medicine

ACR’s Recommendations on Prior Authorizations

In March 2020, the American College of Rheumatology (ACR) made several recommendations to reduce PA requirements and improve access for patients. The recommendations included:

  • Reducing the number of clinicians subject to PA requirements if they are following evidence-based practices and meeting performance measures and other requirements
  • Reducing the number of services and medications that require PA by regularly reviewing and removing unnecessary requirements
  • Improving transparency and channels of communication between payers, patients, and clinicians
  • Protecting continuity of care when changes occur in coverage, payers, or PA requirements, and
  • Accelerating adoption of national electronic standards for PA and improving transparency around formulary decisions and coverage restrictions

The Centers for Medicare and Medicaid Services (CMS) finalized a new rule in January 2021 in an effort to streamline the PA process and improve data transparency for providers, payers, and patients.

The rule will provide certain payers, providers, and patients with electronic access to pending and active prior authorization (PA) decisions. According to CMS, the new rule will:

  • give providers more time focus on providing better quality care
  • promote secure electronic access to data
  • drive interoperability
  • empower patients
  • reduce costs
  • ease the burden on the health care system

Under the new rule, designated payers will have to implement application programming interfaces (APIs), allowing providers to access data through integration with their electronic health records. This data will include claims and encounter information, including laboratory results and data on any pending and active PA decisions.

This is expected to improve the health care experience for patients as APIs will ensure that their providers will have a more complete information about their care. APIs will also allow patients to access their health information more easily.

In a statement released first week of April, CMS stated that recognizing the challenges faced by payers during the COVID-19 public health emergency, the agency will not enforce the new policies and requirements for technology for interoperability and burden reduction until July 1, 2021.

The AMA’s 2020 survey found that medical practices were significantly impacted by the prior authorization burden. Practices complete an average of 40 prior authorizations per physician, per week, which takes up two business days (16 hours) of physician and staff time.

The AMA notes that these findings point to the need to streamline or eliminate low-value prior-authorization requirements to minimize delays or disruptions in care delivery.

“Delayed and disrupted treatment due to an archaic prior authorization process can have life-or-death consequences for patients, especially during a public health emergency,” said AMA President Susan R. Bailey, MD. “This hard- learned lesson from the current crisis must guide a reexamination of administrative burdens imposed by health insurers, often without any justification,” she said.

How Outsourcing Prior Authorization can Help

Insurance authorization services can alleviate the stress of prior authorization for patients and providers. An insurance authorization company will have a team of insurance verification specialists who will work with practices to:

  • Ensure that claims for treatments or services that require PA are submitted promptly
  • See that PA requests meet all of the payer’s criteria before submission
  • Minimize submission hassles and eliminate duplicate procedures

These companies have a streamlined, centralized process in place which minimizes errors. They also have experience working with all government and private insurers. Partnering with an expert helps practices will save time and resources required for getting prior authorizations and reduce risks of denials, benefiting both physicians and patients.

How Insurance Verification Supports Behavioral/Mental Health Billing

How Insurance Verification Supports Behavioral/Mental Health Billing

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.