Behavioral Health billing and accounts receivable

Time-based codes, telehealth place-of-service and authorization limits make behavioral health uniquely denial-prone.

Where the money leaks in behavioral health

These are the recurring denial reasons in this specialty. They are not exotic. They are the ordinary ones that go unworked because the person who could fix them is at the front desk answering a phone.

• Time-based psychotherapy codes not supported by documented duration
• Telehealth denied for the wrong place-of-service or modifier
• Authorization units exhausted mid-course without renewal
• Add-on codes billed without the primary service
• Collateral and family sessions billed under the patient's benefit

What a seat does about it

One trained person works your queue from the difficult end. Every call is logged with the payer reference number and the outcome, so an appeal can quote what was said rather than start again. Denials are categorised, which is how the same reason stops coming back next month. On Friday you get it in writing.

The roles that matter most in this specialty are AR calling and denials at $1,700, prior authorization at $1,900, and certified coding at $2,500.

The codes those turn into

Each of these is a denial code you are likely to meet working behavioral health, matched to the problem above it in your own words. The route back to payment differs by code, so a queue sorted by recovery route clears faster than one sorted by date.

• CO-50 — Not deemed medically necessary
  The payer does not accept that the documentation supports the service. This is a clinical argument, not a clerical one.
  Recovered by being appealed with clinical documentation. Matched from: “Time-based psychotherapy codes not supported by documented duration”
• CO-16 — Claim lacks information
  Something on the claim is missing or malformed. On its own the code tells you nothing — the detail is in the remark code that comes with it.
  Recovered by being corrected and resubmitted. Matched from: “Telehealth denied for the wrong place-of-service or modifier”
• CO-197 — Prior authorization absent
  The payer required prior authorization for this service and cannot find one attached to the claim.
  Recovered by being taken back to the authorization. Matched from: “Authorization units exhausted mid-course without renewal”
• CO-4 — Modifier and code disagree
  The code and the modifier disagree, or a modifier the payer required was not there.
  Recovered by being corrected and resubmitted. Matched from: “Authorization units exhausted mid-course without renewal”
• CO-22 — May be covered by another payer
  The payer thinks somebody else is primary. Until coordination of benefits is corrected on their file, nothing on this claim will pay.
  Recovered by being fixed at coordination of benefits and rebilled. Matched from: “Add-on codes billed without the primary service”

Working a denied claim costs $57.23 per denied claim in administrative time (source), and about about 90% of initially denied claims are eventually paid. Most of what sits in a behavioral health AR bucket is not lost money. It is money waiting for somebody with the hours to make the call.

Questions