Tag: Mental health billing

Behavioral Health Administrative Workers: What are your employees worth?

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A discussion with my coworkers recently reminded me of the wide variability in the size and nature of the organizations that utilize our software products. Behavioral Health organizations range from solo, part-time psychologists, psychiatrists, social workers and professional counselors in private practice to large community-based organizations that provide inpatient, outpatient, intensive outpatient, and home-based care to those requiring mental health and substance abuse treatment.

As a result of this wide variability, the individuals with whom we deal in our provision of technical support services range from highly-trained medical and mental health billing/coding specialists and practice business managers to the teenage child or neighbor of the doctor who happened to be in need of a summer job. We are often amazed by the differences…by how much some billing specialists know and how little information others have.

One of the biggest surprises for me is how often highly trained mental health professionals are willing to entrust their businesses to individuals who have no training to do such a job. We are sometimes asked why our software does not do “x” for them. We explain that the software is a tool to be used by someone who knows mental health/medical billing to accomplish the needed tasks. It will not magically do billing for someone who has no idea how to do that job.

My niece works in a medical practice and is studying for the American Health Information Management Association’s (AHIMA) Certified Coding Specialist – Physician Based exam. I went to AHIMA’s site to see what the content is for this certification and was amazed at the breadth of the knowledge required to achieve the certification. The AAPC is a different organization. . . of professional coders. . . that also offers training, certification, support and networking. Both of these are aimed at individuals who work in medical coding and billing.

Some people who work in behavioral health assume that the billing job must be much simpler for mental health because it contains a much narrower range of services than a general medical practice. Just ask any experienced behavioral health billing specialist, and you will find out that it is not simple at all. Just because the range of services provided in behavioral health is much smaller does not mean that the person doing the billing requires less knowledge about billing and collections and dealing with insurance carriers.

Mental health services were “managed” by insurance carriers much earlier than most other specialties. As a result, there are rules and requirements for obtaining authorization for treatment that have a 30 year history. While “parity” was legislated in 2008 and the final rule for implementation promulgated in 2010, implementation has been slow and many consumers are not even aware that their plan might cover mental health services at the same rate they cover general medical care.

To expect someone who has never worked in a health care setting and has not previously done medical or mental health billing to have any idea about parity or treatment authorizations or copays or coordination of benefits or take-backs is just not reasonable. Medical billing is complicated and behavioral health billing has its own subtleties and complexities that are different.

So what is an employer to do? Here are some quick suggestions:

  1. Recognize that the person who is doing your billing is running a crucial part of your business. You should expect them to be a business professional.
  2. Do NOT expect someone who earns minimum wage to know how to do behavioral health billing. If you find a qualified biller who is willing to work for such a wage, they are selling themselves short.
  3. If your staff is struggling with how to bill, get them information. The Center for Medicare Services (CMS) is an outstanding resource. If a claim will pass Medicare muster, it will also pass the requirements of most other insurers.
  4. Invest in training for your staff. Having your staff thoroughly learn the software product you are using will earn money for your organization.

This is an arena in which I am sure many of you have experience and opinions. Please share your comments below. If you have additional recommendations for employers, please let us know.

Electronic Claim Filing for Secondary Insurance

Posted on | by SOS Blog | 3 Comments on Electronic Claim Filing for Secondary Insurance

Our technical support and customer service staff regularly discuss questions our customers commonly ask. They often answers these questions in emails—repeatedly. For a long time, we have tried to answer some of these questions in documents to make it easier for our customers to succeed in their jobs. The Document Library page on our web site has always aimed to achieve that goal. This year, we implemented new and additional documents in a blog format on our web site as another way for our customers to get answers to their questions quickly.

Electronic claims filing is one of those areas where questions abound. No matter how many times we answer the same questions, we always need to come up with new and different ways to communicate information that is very familiar to us but not so apparent to our customers. This is the same kind of task psychotherapists and others who work with people in any capacity have to accomplish—coming up with different language and presentation of an idea so it can be heard and understood by the person being addressed.

Our lead technical support rep, Manon Faucher, recently wrote an article about how to file claims for secondary insurance carriers electronically. I have borrowed heavily from her article to address the issues that are crucial in successfully filing electronic claims for secondary insurance payers, assuming that the clearinghouse or site through which you send your electronic claims allows submission of secondaries and the payer to whom you are sending can receive secondary claims electronically.

In order to successfully submit secondary insurance claims, it is essential that you include the information about how the claim was adjudicated by the primary insurer. Doing so requires specific data in certain loops and segments of the 837P. If you are an SOS Software user, you should read Manon’s document. She created detailed instructions with screen shots for our product. If you use a different software product, you will need to find out from your vendor whether you can enter and they can report the necessary information to file the secondary claims.

  • Primary payer– You must be able to indicate the order of liability for payers. Make sure you have the Primary set as such for this claim.
  • Secondary payer– You must be able to designate this payer as Secondary for this claim. You must also be able to enter the “Amount received from other insurance”, information that would go in box 29 on the CMS 1500. This should go into the 2320 loop, segment AMT 02.
  • Verify the Claim Adjustment Reason (CAR) amount– If you have received an Electronic Remittance Advice (ERA) that automatically posted your payment from the Primary payer, you will need to determine that the total of the CARs matches the amount of the date of service Fee minus the payment from the primary insurance. Examples:

Denial – no payment by Primary

Fee for service $200
– Primary insurance did not pay for the service so $0 payment is entered for a Denial
CARs must equal the entire fee, $200.00

Partial Payment and Adjustment

Fee for service $200.00
– Primary insurance paid $120.00 and an adjustment of $30.00 was required from the payer
Amount of your CARs will have to equal to $80.00 ($200-$120)

The information from the CARs must be entered in the appropriate segment in the 2430 loop.

  • Adjudication or payment date: Make sure you have entered the payment date in the appropriate place so it will show up in loop 2330B segment DTP 03.
  • Generate and submit the secondary claim.

If your organization is not yet filing insurance claims electronically, it is certainly a service you should investigate. At some point in the future, it will certainly be required that all claims are filed electronically. In the meantime, it is a major convenience and financial savings for providers and organizations.

Maybe it is time for you to get rid of the paper!

Got any observations, opinions, reservations, cheers about filing claims electronically? Please share in the Comments section below. Thanks for reading!

 

 

 

New Year . . . New Plan

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I am in the process of deciding how to proceed with and utilize my blog during 2011. Since you are the consumers of the blog articles, I would very much appreciate your input about how I should do this.

  1. Are there particular topics I have written about that were particularly interesting or useful to you?
  2. Are there certain things you would like me to address?
  3. Do you think the blog is a waste of your time and mine and that I should just let it go?

Please share your thoughts with me. I would like this effort to be as worthwhile as possible. Your guidance will be greatly appreciated. Thanks for reading and commenting when you have the chance!

Kathy

Bits of News for Behavioral Health Providers

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I have recently noticed several pieces of news that I thought would be of interest to providers of behavioral health services and others.

1. The National Council Public Policy Update of April 8, 2010 pointed out an important change in timely filing requirements for Medicare claims:

Requirements of the Patient Protection and Affordable Care Act makes (sic) several changes to the Medicare timely filing requirements. Under the new law, all claims from before Jan. 1, 2010 must be filed by Dec. 31, 2010. Beginning on Jan. 1, 2010, all claims must be filed within one year after the date of service in order to be considered timely.

Sec. 6404 of the law details the requirements. This is a change from the former allowance of 3 calendar years to file a claim. Be clear about this: you now have 1 calendar year after the date of service to file a timely claim for payment for those services.  Now might be a good time to use your billing software to learn which old Medicare claims have not been paid (the claims may have been lost) and if there are any Medicare services that have not been billed. If these are not already three years old, you have only until the end of 2010 to file them, and with services that are new in 2010, you have one calendar year to file a claim for the services.

2. Seth recently posted a message on our User Group about the potential privacy and security problems that can be caused by data left on newer copiers and multifunction machines. NJAMHAA Newswire of May 3, 2010 also commented on the possibility of HIPAA violations that can result from careless use of these machines. Seth’s comments follow:

Now that you finally got all your computer hard drives encrypted and you are feeling pretty smug, here comes another headache — thousands of images containing PHI stored on a hard drive hidden inside other office machines. Take a peek at this investigative report by CBS news:

http://www.youtube.com/watch?v=6pIFUOav2xE

This is a pretty big vulnerability. If you have one of these higher end digital copiers, printers, or multifunction machines and it is stolen — or you neglect to remove or wipe the hard drive before selling or trading it in, you have a reportable security breach. Nobody would be likely to have a list of the patient documents that had been copied over the years, so you
would have to assume that EVERYONE’s protected information was at risk. That means reporting to the Feds, taking out the newspaper ad announcing your negligence, and the rest of the breach notification nightmare!

Apparently all major manufacturers offer security add-ons of some sort. Now would be a good time to inventory your document devices to determine if they contain hard drives and whether you can retrofit appropriate security add-ons to avoid a potentially disastrous situation in the future.

3. The National Council on April 23 published a review of Parity Act implementation that will allow you to determine whether your insurer or the payer with which you are dealing is in compliance with the Parity Act. Is your insurer in compliance with the Parity Act? will help you ask the right questions and provides resources to help you answer the question.

4. On April 22, FierceEMR and other sources reported that hospital-based doctors are now eligible for ARRA incentive payments for meaningful use of certified EHR technology, and that a bill has been introduced by Rep. Patrick Kennedy (D-RI) and Rep. Tim Murphy (R-PA) seeking to include mental health professionals, Community Behavioral Health Organizations (CBHOs), psychiatric hospitals and chemical dependency programs in the ARRA incentives. Time will tell what will fly.

5. And finally, the Mercom Capital HIT Report of May 3 indicated that HHS is seeking comment on the anticipated impact the stricter disclosure reporting requirements included in the HITECH Act will have on providers.

To help guide the Health and Human Services Department in tightening rules for health information privacy, HHS has asked providers, payers and consumers to comment on the benefits and burdens of accounting for the disclosure of protected health information, even if the data is intended for treatment and billing purposes. The HITECH Act called for HHS to strengthen the privacy rule of the Health Insurance Portability and Accountability Act (HIPAA). With the changes, providers, plans and their business partners will have to account for disclosures of patient information contained in an electronic health record, even if the data is for healthcare provision and payment. 

HHS’ Office of Civil Rights (OCR), which oversees health information privacy, published a request for comments in the May 3 Federal Register 
“to inform our regulations under the HITECH Act,” according to the announcement. Under HIPAA, providers and plans currently do not have to report releases of protected data when the disclosures are related to patient treatment, payment and healthcare operations. HHS said in the notice that it will remove the exemption for those disclosures when it involves an electronic health record (EHR).

Needless to say, there is a great deal going on in the world of behavioral health care and health care in general. Please feel free to share news items you discover that might be useful to other readers.

Don’t forget, your comments are always welcome. Please share them below.

Parity Interim Final Rule Guidance Released

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On January 29, 2010, the federal departments of Health and Human Services, Labor and Treasury released their “guidance” on the Wellstone-Dominici Mental Health Parity Act. The National Council discussed some of the contents of the Interim Final Rule (IFR) in their February 4 Public Policy Update. The IFR goes into effect April 5, 2010 and applies to policies with plan years that start on July 1 or later.

Since some insurance carriers have already begun changes in their policies and claims filing procedures in an attempt to meet the requirements of law, it is possible that procedures just put in place may be changed. For example, Blue Cross/Blue Shield of Florida, a company that had a limit of 25 sessions per year for psychotherapy with no authorizations required for most plans, in January started to require authorization for all mental health services. According to the information provided by The National Council, this may need to change again.

Group insurance plans for groups of 50 or more may need to carefully match how they manage medical/surgical and mental health/addictions benefits. It is not just the “quantitative limits” that must be the same; the “non-quantitative limit” also must be the same. The IFR forbids plans from using specific non-quantitative limits unless similar restrictions exist for medical/surgical benefits: medical management, prescription formulary design, “fail-first” or step therapies, and prior authorization.

The National Council has continued discussion of the IFR in several articles on their web site. Take a look at their press releases, policy issues and resources, and slides and recording from a recent health care reform webinar. The National Council does a wonderful job of staying on top of and advocating for issues of this sort and should be on your radar all the time.

The American Psychological Association also advocated strongly for this law and information about its implementation can also be found at the APA web site. More detailed and current information about the IFR has been shared with state psychological associations and should be available to APA members who are connected with the practice organization. The email I received through Florida Psychological Association contained a thorough analysis of the IFR along with examples and hypotheticals. A quick read of this article suggests that it will not be a simple matter for a provider or a consumer to determine if their insurance carrier is following the rule. I am hopeful that simpler guidelines will follow.

Dr. Ronald Manderscheid’s article in Behavioral Healthcare Magazine suggests that this law is just the first step in our move toward parity in payment for mental health and substance abuse services. Four other doors need to be opened more widely to assure true parity: 1. the extension of insurance benefits to more individuals and the extension of the rule to more policies; 2. clear statement of what determines medical necessity for access to care; 3. improving scope and quality of the care accessed; and 4. expecting the outcome of care to be at least as good as in the medical/surgical realm. This law brings us a long way toward the goal of equity, but we as advocates have a long way to go to assure that consumers of mental health care can actually get the care they deserve.

What effect do you think the parity law will have on your organization? Do you foresee a big impact or a small change? Please share your comments below.