Avoid These Common Substance Abuse & Rehab Billing Mistakes
Treatment for substance abuse and rehab have not always been covered by insurance. This addition has proven beneficial for patients and their communities. However, the fact that these treatments can be billed does not mean that they will be paid.
Whether a facility is billing a private insurer or government payer, such as Medicaid, getting paid requires filing a claim just like it does for any medical procedure. Any error on that claim form or even the tiniest piece of missing information will result in the provider being denied payment.
Errors such as an incorrect date or transposed digits can occur in all kinds of medical billing, and claims should be carefully reviewed before submission to ensure that no careless mistakes will result in the claim being denied or rejected. There are also aspects of medical coding and billing that are unique to substance abuse and rehab, which make it important to have expert billers and coders who are experienced with this particular field.
Pay to Patient Checks Are an Issue
In some cases, the insurer will issue the payment for services to the patient instead of sending reimbursement directly to the provider. This often results in the provider not receiving their reimbursement.
A very important aspect of managing this kind of problem is communication with the patient up front. They must sign an agreement before receiving treatment promising to use any money received from their insurer to pay the charges made by the facility. It is important for the provider’s billing staff to know which insurance companies make payments directly to clients so that they can make a point of speaking to the patient and getting their agreement that the reimbursement payment must be given to the facility.
Fortunately, it is becoming less common for the payment to be sent to the patient in these cases. Being handed a check for a large sum of money can easily be the undoing of an addict fresh out of treatment. It has happened far too many times that not only does the treatment center not get paid, but the patient uses the money for drugs and ends up right back in addiction. The practice of sending insurance payments directly to people recovering from addiction has been outlawed in 27 states, which is good for patients and providers alike.
Billing the Wrong Insurer Results in Rejected Claims
While it may be obvious that you must bill the right insurance company, the identity of the company isn’t always as distinct as you might think. Sometimes a business acquires another company and keeps it intact as a separate operation under the corporate umbrella, with a suffix or slightly different name. Insurers have also created subsidiary companies to meet the requirements of different states under the Affordable Care Act. For example, Blue Cross Blue Shield has business entities specifically for providing coverage in Florida and if a biller sends the claim to a different Blue Cross Blue Shield operation, it will be rejected because the patient’s ID number will not show up in their records.
Billers must make sure to match the exact name of the insurer to the correct contact information for submitting claims.
Procedure Codes Must Match Diagnosis Codes
Each diagnosis has approved procedures associated with it and if the treatment is given without the correct diagnosis code being used, the claim will be denied. The reason for this is that the insurer will not consider it “medically necessary.” Coders need to be aware that each diagnosis has one or more accepted treatments and should know what they are. If there is not a good match, the physician should be asked for clarification before submitting the claim.
Consultations Between the Treating Physician and a Specialist Consultant Are Billable
There is a category of CPT codes called “Interprofessional Telephone/ Internet/Electronic Health Record Consultation” that includes billing for instances in which a treating physician or other qualified health care professional seeks treatment advice from another physician who has specialty expertise. The consultant can speak with the treating physician without seeing the patient face to face and it is still billable.
Failure to Follow Up on Claims Causes Lost Revenue
Up to 25% of potential income is being lost by substance abuse and rehab facilities because they don’t have effective (or any) processes in place to collect on their bills. There are many reasons that claims are rejected and denied. Some of them have been discussed here, but there are many more. Most are easily avoidable, but the medical coding system is complex and billing can be challenging.
When a claim comes back unpaid, the insurer/payer must provide a reason, but these can be pretty vague. An experienced biller needs to review the claim, find the cause of the problem and correct the information or provide the necessary explanation or documentation to get the claim paid. It is very difficult for in-house billers to keep up with ongoing billing and still have time to examine unpaid claims, so millions of dollars are lost every year.
Medcare MSO is a medical revenue cycle management company with a long track record of streamlining medical billing processes and increasing revenue for our clients. Call us at 1-800-640-6409 today to find out how we can help make your treatment or rehab facility more financially sustainable.