By Kevin O’Neill
Client Account Executive, Streamline Health, Inc.
As a Client Account Executive working in HIT, I’m well aware of the challenges that providers face when preparing and submitting claims for their services. However, my first encounter with this occurred well before my professional life began. While still a teenager, a relative was receiving psychiatric care and our family was involved in a protracted challenge with getting the claims paid (a process that eventually involved collections, which is common for behavioral services that often reside on the fringe of covered benefits). I vividly recall the stress and impact this process had on all involved.
Many years have passed since then but the problem remains for both providers and the patients they serve. As a former Director of Care Management of a large psychiatric facility, I saw firsthand the struggle providers have between doing the right thing and being financially responsible. Behavioral care is unique in that there’s tremendous variability in what’s covered from one plan to the next, and patients often bring unique challenges to the process, which further complicates the ability to serve—and be adequately reimbursed for— this population.
If you are not an expert in the psychiatric and revenue cycle space (and let’s face it, most of us aren’t), here are five things you might not know:
- Denials are a common issue and comprise 25% or sometimes higher of your revenue. There are two kinds of denials; clinical and informational. Clinical denials occur when the insurance company denies coverage due to lack of medical necessity. Informational denials are often based on administrative issues, which can be as simple as the patient not having their insurance card, to incorrect data entry documenting such an incorrect birthday.
- Psychiatric patients may be in crisis and either cannot remember or are not able to provide basic information. For adolescents and for some adults they have guardians that you must consult for consent for treatment. These complex psychosocial factors can contribute to higher rates of both kinds of denials and the subsequent challenges of appealing them.
- Many hospitals and clinics have limited or no strategy for addressing their denials. They suffer from being poorly funded, which leads to limited investment in collections and denials management. This lack of process and vision contributes to less revenue and consequently less cash on hand.
- Clinical and information denials are preventable. Establishing a length of stay within 24 hours of admission can give your treatment team a goal to work towards. Establishing a solid workflow and quality checks at the time of admission can ensure co-pay collection and correct insurance gathering while the registrar is working with the clinicians to admit the patient.
- Families are willing to help with care management but are seldom asked to help with their denials. Often the patients receive bills for their denied care and are paralyzed with the appeals process. Behavioral health providers rarely truly partner with their patients to address denials due to lack of process and understanding. Again, limited resources can contribute to this.
Streamline Health understands that many psychiatric providers have less than three days of cash on hand. By partnering with these providers to deliver guidance and solutions that increase their financial health, Streamline strives to help them receive the reimbursement they deserve more quickly so they can focus on providing better care to their patients.
To share this insight, I developed this infographic to demonstrate how providers can operationalize their approach to managing denials. Please reference this and connect with me to share your thoughts on the challenges you face —and results you’ve achieved— as a behavioral health provider seeking to adequately fund your mission. I can be reached at firstname.lastname@example.org