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A total solution of Behavioral Health RCM services, from beginning to end. Credentialing, Eligibility, Coding, Billing, and Denial Management are a single, connected Revenue Cycle. We file for Mental Health practices and facilities in all 50 states. This is Mental Health RCM Services, centered on one specialty and not fifty.
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Credentialing, eligibility, coding, billing, and denial work as one cycle
Nationwide behavioral health billing, remote and EHR-integrated
We bill behavioral health only, not fifty specialties at once
Optum, Carelon, Evernorth, Magellan, and Lucet routed correctly
Behavioral health claims are denied where medical claims are not. The benefit is from an independent entity. The codes are time-dependent and subject to underbilling. Authorizations expire at different levels of treatment. The reason for each is unique to things a general biller doesn’t look out for. The following are the most prevalent.
A majority of commercial insurance companies split behavioral health from the rest of the medical plans. The card will say Cigna or Anthem but the benefit is actually through Evernorth or Carelon. Claims submitted to the medical payer go nowhere. Routed to the incorrect payer is one of the most common reasons for behavioral denials.
Psychotherapy codes depend on the duration of the session. Codes 90837 and 90834 are 53 minutes and 38 minutes, respectively. The wrong code results in either underpayment or triggers an audit. Any add-on code for psychotherapy and same-day medication management services is stripped out, and the fee income does not materialize.
Certain higher levels of care require concurrent review. Days are approved in chunks, not all at once. The lack of concurrent review renders any provided care into unauthorized days. This is the quickest way for the facility to lose money through leakage.
The Parity Act prohibits plans from restricting access to mental health or substance use disorders treatments stricter than medical services. A generalist coder may never notice a non-quantitative treatment limitation. This means the more stringent limitation will remain, and denied claims will stand. A parity-focused appeal will recover such denied claims.
Medical benefits and behavioral benefits for patients are usually separate concepts. Verification of the medical side assures coverage that does not relate to therapy in any way; the claim, therefore, denies the benefit that was never applicable in the first place. Only verification of the behavioral side is the necessary safeguard of the claim.
What makes the difference in just one sentence: while generalist RCM companies approach mental health as just one specialty card out of fifty, Mental Health Billing Services approaches it as an entirely separate company. All the mistakes made above are caused by the rules set by the payer which only a behavioral health specialist can catch in time. None of these five mistakes is on the general RCM checklist. Generalist billers use the exact same process for verifying both dermatology claims and psychotherapy claims until one of three things happens: the carve-out, the time band, or the concurrent review. Only then the process will fail silently and the practice will be able to see only the delayed payments.
The revenue cycle is made up of three stages. The front-end initiates payment prior to delivery, by credentialing, eligibility, and authorization. The mid-cycle turns clinical documentation into clean claims, through coding and charge capture. The back-end gets the money, through submission, posting, and denial management. Each stage has its own distinct source of revenue risk.
The stages link in order, and failure in one stage jeopardizes the success of following stages. Failure at credentialing in the front-end stage means failure for the back-end claims regardless of how clean the coding is. A failure to identify eligibility means a mid-cycle claim was already destined to fail prior to being coded. Each stage below links to the service responsible for it, thus providing mechanics of the revenue cycle one click away.
Initiate payment prior to delivery
Credentialing involves payer credentialing that allows provider enrollment and network billing. Eligibility ensures behavioral rather than medical coverage. Prior authorization needs to be collected before service delivery, since absence of the latter means denied claims.
Credentialing and enrollment →
Insurance eligibility verification →
Turn documentation into clean claims
Certified coders assign the CPT and HCPCS codes the documentation supports. Charge capture records every billable service from the session. Claim scrubbing catches errors before submission, so a preventable rejection never reaches the payer.
Medical coding →
Medical billing →
Collect and resolve every claim
Claims go out and get tracked to a decision. Payments post from the ERA and reconcile against the EOB. Denials get worked and appealed, and aged A/R gets chased before a filing window closes.
Payment posting →
Denial management →
Each process has a unique service behind it. Five interconnected services form the entire cycle. Every process has a page that describes its mechanics in detail.
Credentialing and enrollment with payer, CAQH attestation using the right taxonomy to make sure your claims are paid in-network starting from the effective date.
Behavioral-benefit eligibility check before the patient’s first appointment. Make sure that the patient is covered, copay and the need for pre-authorization.
CPT & HCPCS coding performed by certified coders based on the documentation and time-based psychotherapy band.
Submission, scrubbing, and payment posting of claims with a tracking of every claim from 837 file to remittance posting.
Appeals and corrected claims handling by CARC reason codes, including parity-based appeals a generalist biller will miss.
Chasing aged claims by payers and root cause of non-payment, tailored for the small-balance composition of the behavioral practice.
Want to see how these five services would run for your practice? Talk to a behavioral health RCM specialist.
The in-house biller has to bear a salary cost, software costs, and training costs for an unpredictable number of claims. On the other hand, the outsourced team charges according to a certain percentage of collection. However, the real issue lies in knowledge. While an in-house biller acquires experience on the job, an outsourced team already knows Optum from Carelon.
| Where it matters | Outsourced to MHBS | In-House Biller |
|---|---|---|
|
Cost structure |
One percentage of collections |
Salary, software, and training, fixed |
|
Coverage risk |
A team, never out sick |
One person, a key-person risk |
|
Carve-out knowledge |
Knows each MBHO’s rules already |
Learns each payer on the job |
|
Parity appeals |
Filed as routine |
Rarely recognized or filed |
|
Scaling |
Absorbs volume as you grow |
Needs a new hire per jump |
Outsourcing your behavioral health revenue cycle depends on focus. An outsourced revenue cycle frees up clinical time and employs staff familiar with the payers. Behavioral health revenue cycle management is all about focus, where those managing the cycle will only see behavioral health claims throughout their day. The economics of outsourcing favor most sizes of practices. You are paying a salary plus benefits and clearinghouse charges, plus continuing education of the in-house biller, which will be paid whether you increase claim volume or not. The percentage-of-collections model follows the practice. When one biller is away from work or leaves, an in-house cycle grinds to a halt, and claims are filed beyond their filing deadlines. A team handles the risks of that without any downtime. What is the unseen cost of this? The appeal for parity was never made. The carve-out claim was never routed. The revenue left behind by the generalist.
Revenue leaks occur in small amounts and repetitively. Each lost add-on code, each denial that goes unappealed, and each old A/R account costs a small amount on each claim. Over an entire session volume, the total becomes very big. The diagram below represents the same office but in a leaky cycle versus a managed cycle. Illustrative monthly model, a hypothetical group practice
| Line | Leaky cycle | Managed cycle |
|---|---|---|
|
Sessions billed per month |
1,000 |
1,000 |
|
Average allowed per session |
$120 |
$120 |
|
Add-on codes captured |
Often missed |
Captured on the claim |
|
Denials worked |
Left aging |
Worked and appealed |
|
Net collection rate |
Lower, with leakage |
At benchmark |
There are only a few numbers that can define a revenue cycle. The clean claim rate and first pass resolution give an idea of the number of claims that get paid without requiring reprocessing. Days in A/R tells how fast the money is coming in. Net collections show how much is yours.
| Line | What it measures |
|---|---|
|
Clean claim rate |
The share of claims accepted on first submission, with no rejection. |
|
First-pass resolution rate |
The share of claims paid on the first try, without an appeal. |
|
Days in A/R |
The average time from billing to payment. MGMA puts a strong figure under 40. |
|
Net collection rate |
What you collect of the amount owed after contractual adjustments. |
|
Denial rate |
The share of claims a payer denies on first submission. |
|
A/R over 90 days |
The share of the balance aged past 90 days, where collection risk rises. |
We report these monthly, with the aging detail behind each one. Targets are set against published benchmarks from MGMA and HFMA, not against invented numbers. A rising days-in-A/R figure or a slipping clean claim rate is the earliest signal that a cycle needs attention.
These measures have a greater impact on behavioral health than they do in general healthcare. A billing practice runs high volume and low dollars per unit of charge. The lower denial rate will quickly become significant monetary value. Days in A/R will stretch while carve-out claims remain misdirected within the medical plan. The clean claims rate will be affected if time-based coding fails to meet its criteria. This reading of each measure in light of the behavioral environment rather than some target is what makes the KPIs actionable.
Behavioral health is a practice in multiple formats. An independent provider, group psychiatry practice, and facility each bill using different revenue guidelines. We handle the process for all three along with practices that start with telehealth visits. The revenue guidelines differ by format, and each requires staff familiar with their payers.
Psychiatrists, PMHNPs, psychologists, and master's degree providers each have their own codes. Psychiatrists code E&M with therapy modifier codes, whereas social workers do not. The license dictates how the claim is coded. The type of provider depth resides in our behavioral health billing section.
Detoxification, residential, partial hospitalization, and intensive outpatient programs bill using institutional claims. They use revenue codes and condition codes that an independent provider can't use. Whether the days pay comes down to concurrent reviews. The facility billing mechanics reside in our facility billing pages, accessible from our behavioral health billing pillar.
A telehealth session bills with a place-of-service code and, on many payers, modifier 95. Place-of-service 10 marks the patient at home, and 02 marks elsewhere. Audio-only rules vary by payer. A session billed under the office code denies where telehealth applies.
Benefits of behavioral health typically go through a different company. The managed behavioral health company reviews the claim, not the medical plan. Routing to the appropriate company is the first criterion in determining whether to pay the claim. This is the payer expertise that a general biller doesn’t have.
There are five carve-outs that provide most commercial behavioral benefits. Optum Behavioral Health provides benefits for UnitedHealthcare members. Carelon provides benefits for Anthem members, and Evernorth provides benefits for Cigna. Magellan and Lucet provide benefits for other insurance companies. Each company has its own portal, panel, and authorization criteria.
A behavioral claim submitted to the medical plan gets no response back. This is because the benefit was not present at all. We verify the carve-out prior to submission and send the claim to the company which adjudicates it. This is the number one reason for no response denials in behavioral health.
Medicare provides behavioral health services under its own criteria and fee schedules. The state Medicaid programs then have yet another layer, typically in the form of the managed care program. Medicaid fee schedules, taxonomy registration, and authorization criteria differ by state. We monitor each one based on the states where the practice operates.
A carve-out is not simply about which insurance is being billed. It alters what is needed in the eligibility test. A medical benefit plan and a behavioral benefit plan may be subject to different deductibles and authorization requirements. Checking specifically for behavioral health eligibility is the only way that captures the reality of what the billing must pass.
Compliance in behavioral health is protecting the revenue stream, not creating paperwork. The HIPAA laws apply to all protected health information. There is a second federal rule about handling the substance use records differently. The third rule is the legal basis for appeal when the denial a generalist accepts. These rules influence payments.
The HIPAA sets the minimum requirements for handling protected health information. All claims, remittances, and records follow this regulation. A billing partner must comply with it for each transaction. The workflow is developed according to it from intake to posting.
There is an additional layer of protection for substance use disorders records under the 42 CFR Part 2 regulation. This rule manages the release and disclosure of the records. This regulation impacts the claim data processing and release of information processes. It is generally ignored by the generalist biller.
The Parity law forbids a plan to regulate behavioral health treatment more strictly than medical treatment. This means that the denial can be appealed.
We operate within the systems which your practice is already using. Thus, the existing Behavioral Health EHR and Practice Management system stack, without any forced migration. The software vendors try to offer a platform swap, but we make the exact opposite choice. We integrate into what you use and process the cycle through it.
We invoice from SimplePractice, TherapyNotes, Tebra, Valant, AdvancedMD, athenahealth, and more. We interface with the clearinghouses processing the claims such as Availity, Waystar, and Change Healthcare. No other platform is required to be learned or mastered and no data migration is required. Your team keeps its existing workflow, and the revenue cycle processes through the system you are already using.
In stark contrast to what a software vendor provides, the EHR platforms that get good rankings for behavioral health billing start with migrating your notes, your calendar, and your history into their system. We enhance your trusted system by providing a billing team with your system. It is an additional service on your platform rather than a replacement of the same.
We manage the revenue cycle process for behavioral health clinics in all 50 states in the country. Our coverage claim is national due to the lack of standardization when it comes to payers’ policies. The rules on the Medicaid schedule of fees, taxonomies, and authorizations are state-specific. The claim we make of being able to do a nationwide claim means that we should be knowledgeable about each state’s specific rules, instead of disregarding them.
The priority states have the highest volume in terms of behavioral health services provided. Some of the states in which we can do billing include California, Texas, New York, Florida, Pennsylvania, Ohio, Illinois, Georgia, North Carolina, and Michigan. We also include New Jersey, Virginia, Washington, Arizona, Massachusetts, Tennessee, Indiana, and Missouri in our billing process.
We bill one percent of collections. Payments are made only when you get paid, and there is no lock-in for the long term. Our charges will vary based on how much the billing cycle has collected, thus putting us both on the same page regarding incentives.
The percentage-of-collections system is a system where our pay is directly related to your performance. When a case gets billed and is successful, we make money; if it fails, we don’t. This ensures that our priorities remain to ensure successful billing of all cases.
The mental health revenue cycle management is the entire financial cycle of a behavioral health facility. The cycle begins from the initial visit and insurance verification through coding, claims submission, denial management, and the receipt of payment. Each part of the cycle is related to the other. An interruption anywhere along the way will result in loss of income the practice has already generated.
One element of the cycle is the actual submission of a claim and the posting of the payment. The billing process is just a portion of the overall cycle of the business. Revenue cycle management begins even before the first visit through the processes of credentialing and eligibility determination. It ends after every penny of the payment is received.
Behavioral claims have inherent risks that general medical claims lack. The value is with the carve-out company and not the medical plan. Psychotherapy codes are time-based and easy to under-code. Authorizations expire in higher level of care cases. This is just one of many risks we monitor for on our side.
Yes. We handle billing within SimplePractice, TherapyNotes, Tebra, Valant, AdvancedMD, athenahealth, and others. Our system integrates with clearinghouses like Availity, Waystar, and Change Healthcare. We require no migration and no need to adopt a new platform. Your staff maintains their current workflow.
We have one flat percent of collections models. You pay us once you collect from the payers. There is no lock-in and no software cost. This allows for the incentives of each billing cycle to align with our incentives. The exact percent depends on your volumes.
We bill the managed behavioral health entities such as Optum, Carelon, Evernorth, Magellan, and Lucet. We also bill Medicare and state Medicaid, including Medicaid managed care programs. Each carve-out and program maintains their own rules, and we direct each claim to the organization that processes it.
Free revenue cycle assessment
Send us 90 days of your claims, and we’ll help you discover where the revenue cycle leaks. We identify misrouted carve-out claims, lost add-on codes, denied claims not worked, and aging A/R. Phone (860) 500-1471 or submit the form.
Simplifying mental health billing with accurate claims, faster reimbursements, and seamless revenue cycle management.
