Does your claim pass the AI and prior authorization automated systems?
1 out of 4 mental health claims are denied and that is more than double the rate than in general medicine. Payers have implemented an automated prior authorization and claims review system. It's more than documentation and coding correctly. If your denials have been creeping up the past six months or year, take a look at the operational infrastructure in A/R. Some EHR's can verify eligibility. It does help to know the coverage policies like in-network for Telehealth or in-person consult, is a pre approval needed and protocols in place for the medical necessity and the level care the client needs IOP, PHP, residential, SUD and length of stay, document measurable outcomes.
When a denial happens, review it for triggers at each touch point in the patients care. This where knowing parity law enforcement for your state and mention it in the appeal process. Is it worth it doing an appeal, yes! We are not trying to outsmart the algorithm in the automated process and this isn't going away. I'm not a betting person, but with mental health and behavioral health to rework a claim is the range $25-$70 and the system is betting on that you won't fight the claim.
Prevention tips to develop a practice template or protocol
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Minimum 48-72 hours before a visit, verify coverage eligibility in real time.
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What is medical necessity and have the right documents, progress, metrics being used, time codes & modifiers to prevent gaps.
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Review claims against the payer and state rates.
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Administration, complete all notes before submission same day or next day.
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Track top 5 payers on your appeal success. Stay current on policy changes.
Control what is controllable and what is not is critical in denials & appeals.
