Navigating Complex Payer Processes in Behavioral Health

By Ram Krishnan, CEO, Valant
LinkedIn: Ram Krishnan
LinkedIn: Valant

Navigating payer stipulations in behavioral healthcare can be a challenge, as they are often more complicated than those for physical healthcare. However, understanding how to maintain compliance and bill properly is something that behavioral health clinicians and practice owners have to do to maintain business efficiency, avoid revenue losses, and provide timely care to patients.

Understanding Complex Payer Rules in Behavioral Health

The rules that payers set dictate how much and what type of information clinicians gather on patients, which billing codes to use, how to document treatment, and which treatments are covered. Every part of the billing process, front to back, is subject to these rules.

Here are a few common examples of complex payer rules for behavioral healthcare, and how they differ from payer guidelines for physical healthcare.

• Not all payers cover the same behavioral health treatments. Service coverage tends to be more nuanced and restrictive than physical healthcare coverage.
• Payers use more numerous and specific billing codes within behavioral healthcare. The ICD-10 codes for mental health are more granular, including distinct codes for different subsets of diagnoses.
• Most payers mandate a heavier documentation load for behavioral healthcare. Mental healthcare claims usually require more documentation than physical healthcare in order for payers to provide coverage.
• Mental health parity laws have raised expectations for documentation and justification of treatment. They also require payers to demonstrate how their mental health coverage is on par with general healthcare coverage. That requires capturing more information about behavioral health patients, their conditions, and their treatment.
• The rules are subject to frequent changes. Parity laws continue to evolve with ongoing legal and regulatory guidance. Behavioral health providers have to continually adapt.
• Mental health treatments are more likely to require prior authorization, introducing additional time, administrative work, and room for error in the care delivery process.

How Complex Payer Rules Can Affect A Practice

Lower Revenue
Getting paid well for behavioral healthcare services requires accurate coding, clean claims, and prompt responses to aging or rejected claims. Incorrect coding may cause a high number of rejected and denied claims: an administrative headache and revenue killer. Few behavioral health practices have the time to manage large numbers of claims denials; inevitably, some fall through the cracks and never result in compensation.

Administrative Burden
Behavioral health practices juggle plenty of administrative tasks, between capturing patient information, documenting treatment, and billing. The more complex the payer rules, the heavier the administrative workload, and the fewer patients providers have the bandwidth to treat.

Delayed Care
If a practice doesn’t carry out the prior authorization process efficiently, patients will have to wait for treatment. Not only do these delays impede patients in accessing care, but it may discourage some clients from getting help at all. If clients feel that insurance coverage will be confusing, they may opt out of treatment rather than risk an unexpected bill.

How to Navigate Complex Payer Rules Like a Pro

To successfully handle billing, even with complex payer rules, practices should:

• Proactively monitor changes to the rules. Remember, legal interpretations can shift and payers can adopt new strategies. Stay informed, and be ready to adapt.
• Develop streamlined documentation processes. Staff and providers should have clear-cut steps to follow to capture relevant data. Without a shared protocol, they’re more likely to make mistakes, and the documentation may be of disparate quality.
• Train staff on payer-specific requirements. Don’t assume they already know the ins and outs of these regulations, even if they have years of experience in the behavioral health field. Mistakes made in ignorance still cost money.
• Establish a pre-authorization workflow to obtain treatment authorization as quickly as possible.
• Use a specialized behavioral health EHR for better compliance and speedier tasks.

Leveraging EHR Systems to Manage Complex Payer Rules

EHRs built for the challenges of behavioral health make it much easier to handle complicated, shifting payer rules. Blending functionality with ease of use, these systems create user-friendly and fast workflows for even the trickiest aspects of practice management.

To best navigate payer rules, providers need the following capabilities in software:

1. Payer specific-templates. Customization options should allow practices to create forms and templates that satisfy individual payer requirements. For example, providers may need to create payer-specific treatment plan templates, documentation templates, and billing templates.
2. Library of billing rules. Staff and providers need to have easy access to the rules when they have questions.
3. Custom rule writing. Practices need to be able to update the EHR with particular rules and make changes as payer and legal regulations change. The more updated the EHR, the better the system can support the practice.
4. ICD-10 code library. Billing code protocol should be centralized in order to code accurately and comprehensively for all the services provided.
5. Integrated billing. A billing system should pull information directly from EHR records to eliminate many of the mistakes that come with manual data entry. Cleaner claims and fewer rejections allow practices and staff to recapture precious admin hours.
6. Strong reporting features for billing. Practices should regularly run reports on claims submissions, denials, payments, and aging claims. Staying ahead of rejected and denied claims, helps regain more revenue as fewer bills fall to the wayside.
7. Automated rule-checking features. Software should be proactive in applying rules and catching mistakes.
8. Features to speed up documentation. EHRs should provide auto-generated narration and easy check-box options for compiling progress notes. Paired with templates for each payer, this can tremendously enhance providers’ ability to meet payer requirements without getting bogged down in hours of documentation.

Best Practices for Compliance and Reimbursement

Great software alone won’t guarantee success; implementing best practices for compliance and following them consistently will. As mental health payer regulations evolve, billing audits are key in identifying processes that need adjustment. They can also uncover unusual rejection and denial rates, allowing you to address issues before they severely affect revenue. To stay on top of complex rule changes, frequent audits are crucial.

Next, build relationships with payer representatives. These experts can clarify confusing rules and help resolve claims issues, so maintaining a positive relationship is important. Reach out when you have questions and express gratitude for their support.

Furthermore, practices should leverage other available resources, such as payer portals and industry associations. If a payer portal is available, it likely holds valuable compliance and payer rule information. Industry associations offer news, updates, and best practice recommendations while training from EHR providers can help staff fully utilize billing features and deepen their understanding of compliance details.

The Future of Payer Rules in Behavioral Health

Adaptation will always be the name of the game. Payer rules and billing requirements will continue to change, policy regulations, such as the parity law, will continue to present new requirements, and, fortunately, technology will continue to find fast and efficient ways to deal with the complexity.

The habits built today to navigate complex rules will safeguard practices when change inevitably comes. Stay abreast of updates, create smart processes for compliance and billing, and lean on behavioral health-specific EHRs to ease administrative burdens, protect your practice’s bottom line, and better connect patients with the behavioral healthcare they need.