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, from our office in Rawalpindi, Pakistan, logged into your own system on your hours. 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. Some payer contracts and some state Medicaid programs restrict or require disclosure of offshore access — check yours before placing a restricted queue on this seat (more on /security/).

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

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-198 — Authorization limit exceeded
  An authorization exists. The problem is that you went past what it allowed — more units, more visits, or a longer date range than was approved.
  Recovered by being taken back to the authorization. Matched from: “Residential and partial hospitalisation days billed beyond the authorized span”
• CO-97 — Payment included in another service
  The payer is bundling this code into another one on the same claim. Sometimes that is correct and sometimes it is not.
  Recovered by being worked at the edit pair, with a modifier only where the record supports one. 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 payers ultimately pay roughly 90% of claims even while using an initial denial to slow payment. 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