Shelley Mangum of Illuminate Billing gives us expert advice on how to bill insurance.
Billing in 2022 continues to be a challenge for all, in particular, the predominantly out-of-network (OON) provider. Deductibles and out-of-pocket maximum levels continue to rise. Fewer plans provide OON benefits. Here are some tips to help navigate these and other relevant challenges
- Complete a thorough Verifications of Benefit (VOB) before admit: Accurate and timely VOBs are vital to getting paid. Verification of Benefits is one of the most valuable tools in identifying if a client’s insurance will cover treatment or if other financial resources will be required. Verification of Benefit efforts do not stop once a client has entered treatment. Benefits must be checked at the beginning of each month and policy renewals must be reviewed. When policies renew, while in treatment the deductible and out-of-pocket maximum will reset, possibly causing a significant financial burden for clients.
- Document the essentials: This may be one of the least favorite activities yet mandatory in the claims payment process. Best practice documenting to medical necessity criteria is vital. The tried and true statement: “If it is not documented, it didn’t happen” is more true now than ever before. Claims continue to be denied for lack of documentation. Here are a few claim denial causes:
- Start and stop time of session missing or inaccurate
- The number of participants in a group not noted
- Documentation is not signed by a credentialed individual
- Medical records are not signed by the physician
- The physician has not ordered specific treatment services
- Medical records do not support the level of care billed
- Credentials and/or dates are missing
- Be aware of fraud trends: With fewer available insurance plans offering OON benefits, some insurance brokers have started getting creative by signing clients up on insurance plans in states other than where they reside. Then clients seek treatment in their home state. This is fraudulent in nature. Insurance companies will take action to recoup any revenue paid on such claims. It is not a matter of if, but when.
- Don’t leave money on the table! Appeal: It has been reported that 25%-30% of claims are underpaid. Tracking allowed amounts and appealing for these funds is a fundamental part of running a successful billing organization. (Illuminate Billing Advocates brought in $1,034,000 in 2017 on these and other similar appeal cases.)
- Engage in regular self-care: This item is vital to all aspects of treatment and life. With greater expectations and higher demands on our time, it is easy to get burned out, become apathetic or cynical about our work. The work we do is more than just a job it changes lives. The more we practice self-care the more impact we will have on those we influence. We focus on teaching structure, healthy patterns of living, and recovery skills to our clients but often fail to practice them with the same intensity. For this last item consider doing one or more of the following and note how it improves your overall feelings of well-being:
- Be kind to yourself
- Do an act of service outside of work
- Try a new activity
- Meet someone new
- Schedule your own therapy session
- Connect with friends
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Insurance Billing FAQ
What is Verification of Benefits (VOB) and why is it important for insurance billing? Verification of Benefits is a critical process that determines whether a client’s insurance will cover treatment before they are admitted. VOBs must be completed thoroughly before admission and rechecked monthly, especially at policy renewals when deductibles and out-of-pocket maximums reset, potentially creating significant financial burdens for clients.
How often should I verify insurance benefits during a client’s treatment? Benefits should be verified at the beginning of each month throughout the duration of treatment, not just at admission. Policy renewals require special attention since deductibles and out-of-pocket maximums reset when policies renew mid-treatment, which can dramatically impact coverage and patient costs.
What are the most common documentation errors that lead to insurance claim denials? Missing or inaccurate start and stop times for sessions, failure to note the number of group participants, and unsigned documentation by credentialed providers are frequent denial causes. Additionally, claims are denied when medical records lack physician signatures, don’t support the billed level of care, or are missing credentials and dates.
What should I know about out-of-network insurance fraud in behavioral health billing? Some insurance brokers fraudulently enroll clients in insurance plans in states where they don’t reside, then have them seek treatment in their home state. This practice is illegal and insurance companies will eventually recoup payments made on such claims, creating significant financial and legal risks for treatment providers.
How much money do providers typically lose due to underpaid insurance claims? Reports indicate that 25-30% of insurance claims are underpaid, representing substantial lost revenue for treatment facilities. Tracking allowed amounts and filing appeals for underpaid claims is essential, with some billing advocates recovering over $1 million annually through systematic appeals processes.
Why is medical necessity documentation so critical for insurance reimbursement? The healthcare billing principle “if it is not documented, it didn’t happen” is more crucial than ever for claim approvals. Claims are routinely denied when documentation doesn’t demonstrate medical necessity, when physicians haven’t ordered specific services, or when records don’t support the level of care being billed to insurance.