Behavioral health centers will face unprecedented challenges in 2022, especially larger health groups. With the rise of telehealth services, many centers are expanding beyond state borders, and the more payer types folded into a revenue stream, the more complex the revenue cycle management (RCM) becomes. Self-pay has become one of the easiest and largest pay methods for behavioral health; however, Medicaid, Medicare, and private insurers all have unique rules, requirements, and guidelines to consider. The mere volume you do, the more requirements and guidelines you need to track and follow.
Behavioral health and substance abuse facilities have two basic options when it comes to RCM, in-house billing and outsourced, or co-sourced, billing. The model you choose depends greatly on your business model.
The in-house billing method
With staffing being one of the biggest challenges of 2022, this may not be a sustainable model. If you choose this model, it is important to remember that there are four separate parts to RCM: front-end operations, collections, credentialing and contracting. You need people on your team who are experts in each of these areas.
Insurance denials fall into five buckets:
- Enrollment:
Providers who were not properly credentialed - Justification:
Submitted claims that are not perfectly clean when they are sent off for payment - Coding:
Submitted claims that are not coded correctly or coded for medical necessity - Coverage:
Patient not eligible or billing for a service not specified in payor contract - Authorization:
Authorization required is missing or invalid
If you are going to manage your RCM in-house, you need to have enough resources, so your staff can focus on complex billing guidelines. You should also have a strong EHR billing system, specific to behavioral health, that minimizes risk of human error. If you do not have these two supplements, you should consider outsourcing your billing to a billing company with expertise specific to your specialty.
The outsourced/co-sourced billing method
Since RCM is so complex, many practices benefit from outsourcing. A great deal of specialized knowledge is required for behavioral health RCM, and many facilities have come to realize that their in-house teams don’t have the necessary training, or they don’t have the appropriate number of resources, to handle the volume and maximize revenue.
Selecting the right vendor
Behavioral health and substance treatment facilities should choose a vendor with specific knowledge and experience in the behavioral health field – a vendor that understands how the revenue cycle works specifically to this space.
These are the elements that a skilled behavioral health billing service can handle for you:
- Submitting and resubmitting claims
- Working rejections and denials
- Posting payments
- Working accounts receivable (A/R)
- Preparing and sending client statements
Additional tasks that can be handled by a billing service:
- Eligibility Verification
- Prior Authorization Retrieval (if required)
- Coding
- Contract Negotiations
- Credentialing
If you have a strong internal team in place, you may be able to handle credentialing, prior authorizations, and contract negotiations yourself. If you have a strong EMR, the initial coding could be handled by the providers, and your billing partner can focus on reviewing coding for errors. Keep in mind that, in most cases, it’s wise to outsource the management of claim denials. Experts in RCM denial management know who to talk to, what questions to ask, and what language to use when speaking to insurance companies. This knowledge will increase your chances of gaining approval.
Regardless of which model best fits your practice, select a partner who will come alongside you and provide you with the solution you need.
