Behavioral health billing demands accuracy in coding, documentation, and understanding of payer policies. Even small missteps can result in denied claims, reduced revenue, and interrupted patient services. Here’s an analysis of frequent billing mistakes and the specific steps to correct them.
1. Incorrect Coding
Behavioral health services involve specialized CPT, HCPCS, and ICD-10 codes that differ significantly from general medical billing. For example, psychotherapy sessions have specific duration-based codes (e.g., 30, 45, or 60 minutes), and group therapy sessions have unique codes that cannot be interchanged with individual therapy. Using incorrect codes often leads insurers to reject claims since the details don’t align with the documented service.
For instance, the AMA frequently revises CPT codes for mental health services, which can affect billing accuracy. Providers should establish a training schedule, such as quarterly coding workshops, to keep staff informed about code changes and to review common coding errors.
2. Insufficient Documentation
Behavioral health claims require robust documentation that reflects the patient’s condition, the therapeutic intervention used, and measurable progress or setbacks. Insurers rely on this information to verify the necessity and appropriateness of services.
For example, if a claim indicates crisis intervention services, but the documentation lacks details on the crisis and the immediate steps taken, insurers may deny the claim for insufficient justification.
For example, a standardized therapy session note might include fields for specific treatment techniques (e.g., cognitive-behavioral strategies) and assessing the patient’s response.
3. Misunderstanding Payer Requirements
Each insurer has its own set of rules, which can vary widely. For instance, Medicare may cover only specific mental health services under Part B, like diagnostic evaluations and some types of counseling, but restrict others, such as telehealth services, under certain circumstances.
Medicaid, by contrast, often has stricter criteria for service frequency or session duration. Misinterpreting these guidelines leads to claim denials because the submitted services don’t meet the insurer’s specifications.
Behavioral health practices should maintain a detailed, easily accessible database or reference document that lists payer-specific guidelines for their top insurance providers. This database should include information such as session limits, pre-authorization requirements, and telehealth rules. When rules change, updating this database and notifying billing staff ensures claims align with current payer policies.
4. Lack of Pre-Authorization or Pre-Certification
Many insurers require pre-authorization for behavioral health treatments, particularly for extended sessions or specialized interventions. Without this step, even medically necessary services may not be reimbursed, costing practices both time and money.
For example, if a patient requires intensive outpatient therapy, insurers often mandate pre-authorization to ensure that these more costly services meet specific criteria.
To ensure compliance, integrate pre-authorization checks into the intake and scheduling process. A staff member should be designated to manage authorizations, confirming approval before appointments are scheduled.
5. Unbundling Services
In behavioral health, certain services are billed as a single code when bundled, such as group therapy sessions that include both an initial assessment and follow-up discussion in one appointment.
Unbundling—billing these separately instead of under the bundled code—can cause claim rejections. This often happens when billing staff, unfamiliar with behavioral health codes, mistakenly separate codes meant to be billed as one.
Using billing software that flags common bundling errors also minimizes risk. When bundling guidelines change, update the system to reflect new policies, ensuring claims remain compliant without relying solely on staff memory.
6. Errors in Patient Information
A simple error in patient data—such as an incorrect insurance ID number or a misspelled name—can trigger a rejection. Behavioral health providers often see patients regularly, which compounds errors if inaccurate details are repeatedly submitted.
Simple measures, such as having patients confirm their name, date of birth, and insurance details at check-in, reduce errors significantly. Implementing electronic health records (EHRs) with built-in verification fields can also help catch inconsistencies before claims are submitted, improving the accuracy of patient information across the board.
7. Inadequate Follow-Up on Denied Claims
Denied claims represent lost revenue and may reflect recurring issues that need addressing. For example, claims denied for lacking documentation can indicate an underlying problem with documentation practices. However, some practices lack the resources or process to track and resubmit denials, leading to substantial revenue loss over time.
Assign dedicated time each week for denied claim reviews and train staff to identify patterns, such as frequent rejections from a specific insurer. Using billing software that tracks denial reasons provides insights into systemic issues.
Ready to Streamline Your Behavioral Health Billing?
For expert support in managing complex billing requirements, connect with Synergy Bill Pro. Our team specializes in reducing errors, optimizing revenue, and ensuring compliance with payer guidelines. Reach out to Synergy Bill Pro today to simplify your billing process and improve your practice’s financial stability.
