Substance Use Treatment billing and accounts receivable

Substance use treatment carries the heaviest confidentiality rules in US healthcare and the tightest authorization cycles — levels of care are reauthorised continuously and lapse quietly.

Where the money leaks in substance use treatment

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.

• Level-of-care authorization lapsing between reviews, so days deny retroactively
• Residential and partial hospitalisation days billed beyond the authorized span
• Confidentiality rules under 42 CFR Part 2 breached by a routine records release
• Bundled per-diem billed alongside services the per-diem already includes
• Medication-assisted treatment split incorrectly between medical and pharmacy benefits

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 substance use treatment, 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-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: “Level-of-care authorization lapsing between reviews, so days deny retroactively”
• CO-15 — Authorization number missing
  There is an authorization requirement here, and the number you sent is absent, wrong, or does not cover what was billed.
  Recovered by being taken back to the authorization. Matched from: “Residential and partial hospitalisation days billed beyond the authorized span”
• CO-252 — Additional documentation required
  The payer will not decide until it sees paperwork. Nothing happens until it arrives.
  Recovered by being answered with the document the payer names. Matched from: “Confidentiality rules under 42 CFR Part 2 breached by a routine records release”
• CO-45 — Charge exceeds the fee schedule
  A contractual write-off rather than a denial. It only becomes a problem when the allowed amount is wrong.
  Recovered by being checked against the contract before any work is done. Matched from: “Bundled per-diem billed alongside services the per-diem already includes”

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 substance use treatment AR bucket is not lost money. It is money waiting for somebody with the hours to make the call.

Questions