Helping News                                                   March, 2011   Issue 32

The Reality of Billing:
Note to Providers of Mental Health Services and Clients 
The following was presented from "Mental Health Matters" -

10 reasons providers are not getting paid for mental health claims 
CLAIM REJECTED. You’re not the only one receiving $0.00 payment EOBs. The entire health industry is struggling. Insurance companies have been hit hard by the recession. 

Payments for mental health are even harder to collect. Let’s face it - the only incentive payers have to provide mental health benefits - is the law that says they have to, and often they will require multiple resubmissions that can lead to payment delays months after service has been delivered.

Here are 10 of the reasons providers are not getting paid. There are many more. Some of these are valid errors, but most are arbitrary methods used to stall or avoid paying for mental health insurance claims. 

1. OUTSOURCING – Many insurance companies hire Company B to handle mental health claims. Company B might hire Company C to do re-pricing of the claim. Finding out where to submit claims, who to call for prior authorization or how to obtain payer ID numbers can be a phone tree nightmare. Claim payments are delayed and submission errors produce rejections. 

2. NO PRIOR AUTH – Many insurers require prior authorization for mental health. The number of sessions covered, are usually limited. Back dating for sessions already provided is rare. Obtaining the PA# can take several calls to reach the correct office and long waits on hold. Many claims go unpaid when the PA is not in place at time of service. 

3. HIGH DEDUCTIBLE – The allowed number of mental health sessions are usually too few to reach a high deductible. Unless the patient has other medical claims, their mental health sessions never get paid. 

4. RECOUPING – Insurance companies make payment errors. If they discover an error in their favor 6 months, a year, even two years later…they’ll recoup those dollars from the clinic. They’ll withhold payments from other patients or other therapists in the clinic. It creates an accounting mess. And no, you can’t go back two years and recoup payments on errors in your favor. 

5. LOST CLAIMS – Paper claims get lost (thrown away) at insurance companies. Insurance insiders report that paper claims will sometimes fall off a desk into the round file…especially late on a Friday afternoon. 

6. EOB ERROR CODES – The error codes on your EOB can be in error. Yes, missing data on a claim form will get a rejection. But, sometimes the correct data was there on the original claim submission. The error code was wrong (or created) and resubmitting the same claim will get it paid. Your payment gets delayed. The payer gets to keep your money a little longer. 

7. MEMBER IDs – The member ID numbers are ripe for error. They can include alpha, numeric and sub numbers. They are printed on member cards in tiny type. They are hard to read from the original card and nearly impossible to read when copied and faxed. A one character error will result in a rejected claim every time. 

8. WRONG GENDER – If gender is not indicated on the intake form and the first name is unusual, guessing gender is 50-50 proposition. Consider names like Pat, Jody, Nierra or Rashawn. Those have a 50% chance of rejection for wrong gender if not indicated on the intake form. 

9. DATE OF BIRTH – Every insurance company requires a correct DOB before they’ll pay a claim or even provide benefit information. If it’s missing or hard to read on the intake form - claim submission is a waste of time. 

10. ADJUDICATION – Unpaid claims are often listed as “In Adjudication.” Nobody knows what this means. But you’re not getting paid until the claim is out of Adjudication. 

If it appears that this article is a bit jaded about dealing with the insurance industry – well it is. Some payers and some days are worse than others. Electronic billing is getting claims paid faster. But it also catches every data error. 

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