As physicians focus on providing individualized care for addiction, they also need to ensure precise documentation, proper coding, and accurate billing to reflect the services provided. Although most health insurance plans cover mental health and substance abuse services as essential health benefits, obtaining reimbursement can still be challenging. Avoiding billing mistakes is crucial to prevent denials. Outsourcing medical billing is an effective solution to manage these complexities, ensure accurate claims, and a smooth reimbursement process.
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Common Pitfalls to Watch Out for in Substance Abuse Medical Billing
Here are some common errors that can occur in substance abuse medical billing:
- Not Verifying Patient Eligibility
When it comes to substance abuse, the specific coverage a patient has will depend on their health insurance plan and the state where benefits were purchased. Not verifying the patient’s coverage and benefits can lead to claim denials.
Insurance coverage can change frequently due to a number of reasons such as updates during enrolment periods, plan revisions, change in the member’s address, etc. Eligibility verification confirms a patient’s insurance coverage before treatment. It is one of the first steps in revenue cycle management and helps maintain and improve practice cash flow. It can also help patients understand their financial responsibilities and plan for their treatment. Since insurance verification and authorization for substance abuse treatment can be complex, it is best to have it handled by experts.
- Billing and Coding Mistakes
Understanding the specific codes for services and keeping track of updates is crucial to avoid denials and delays.
- ICD-10 codes: There are thousands of ICD-10 codes for substance abuse (Mental and behavioral disorders due to psychoactive substance use F10-F19). There are specific codes for detox, alcoholism, heroin addiction, and general group therapy. There are separate codes for mild, moderate and severe substance abuse. For example, the diagnosis codes for Opioid Use Disorder are: mild – F11.10, moderate – F11.20, and severe – F11.20.
- CPT codes: It’s important to keep track of updates by reviewing CMS guidelines and local coverage determinations for CPT codes and HCPCS codes and to avoid upcoding and undercoding. Upcoding occurs when you report a higher-level service or procedure than what was actually performed. It can occur unintentionally due to improper documentation or lack of knowledge. Negligence, oversight, or a deliberate effort to avoid audits are the common reasons for undercoding – submitting a lower-level code than what was actually performed. Coding mistakes can result in penalties, loss of revenue and legal consequences.
- Telehealth codes: Telehealth has become a vital component of behavioral health treatments as it provides patients with access to high-quality specialists without the burden of travel expenses. However, telehealth services involve specific insurance codes, which can complicate the billing process. Not adhering to the coding requirements for telehealth claims could result in claim denials.
- Insufficient or Inaccurate Documentation
Substance use documentation errors can significantly impact patient care and legal compliance. If the documentation does not support the services billed, reimbursement can be denied. Proper documentation is essential to justify the need for specific interventions. If the provider fails to document the medical necessity of a treatment related to substance use insurers may not approve payment. Mistakes to watch out for include:
- Incomplete documentation: Not recording all relevant details regarding a patient’s substance use history, such as types of substances used, frequency, and duration.
- Inaccurate information: Documenting incorrect data about a patient’s substance use, either due to misunderstanding the patient’s disclosures or failing to verify information.
- Ignoring legal requirements: Overlooking documentation requirements specific to substance use disorders, which can vary by state and context.
- Failure to update records: Not regularly updating a patient’s substance use history or treatment progress.
- Neglecting to document interventions: Failing to record any interventions or referrals made regarding substance use.
- Insufficient risk assessment: Not adequately documenting risk assessments related to substance use, which are vital for determining appropriate treatment plans.
Poor documentation increases the risk of audits by payers, which can result in recoupments if errors are found. This can affect both current reimbursements and future payments.
- Lack of Pre-authorization or Knowledge of Rules
Some insurance companies require pre-authorization for substance abuse treatment. Approval will be needed from the health insurance plan before providing a healthcare service, carrying out a treatment plan, prescribing a certain drug, or prescribing a medical device. If pre-authorization is not obtained, the insurance company may not cover the treatment.
Not knowing the rules can also delay treatment. Prior authorization for addiction depends on the patient’s specific plan. Laws on prior authorization also vary from state to state. Some state Medicaid programs and private insurance companies require providers to obtain prior authorization before prescribing buprenorphine or other medication-assisted treatments (MAT). Conversely, some states explicitly prohibit or restrict the use of prior authorization by their Medicaid programs or private insurers.
- Late Claim Filing
Submitting insurance claims later than the specified timeframes set by insurers or regulatory bodies is another common mistake. This can happen for various reasons, such as incomplete documentation, administrative errors, or misunderstandings about filing deadlines. Delayed claim filing can lead to denials or rejections, leading to lost revenue for providers and disruptions in cash flow with negative impacts on patient care.
Best Practices to Avoid Errors in Substance Abuse Medical Billing
Implementing efficient billing practices can help avoid these mistakes and ensure timely and proper reimbursement:
- Stay updated: Keep track of code changes and payer rules and ensure compliance with regulatory requirements.
- Understand payer policies: Get to know the specific policies of various payers concerning substance abuse billing.
- Perform insurance eligibility verification: Perform insurance verification to understand patient coverage and benefits before treatment. Verify benefits at each visit to make sure a patient’s benefits are still in place before providing services or billing.
- Ensure correct coding: Make sure to apply the appropriate substance abuse ICD-10 and CPT codes for the services provided.
- Double-check documentation: Before submitting claims, double-check documentation to ensure correct patient and provider information, correct payer information, and correct coding.
Getting reimbursed for addiction treatment is easier when you have expert support. Partnering with a specialized medical billing company can help ensure accurate claims submission and reduce errors. A reliable company will provide comprehensive real-time insurance verification services and also have expert teams that can handle the complexities of medical billing and coding for substance abuse. They utilize advanced billing software and technologies that can streamline processes, lead to faster reimbursements, and enhance practice cash flow.
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