- Posted by Jason
- On March 27, 2017
- 0 Comments
Pre-authorizations and utilization reviews are a core piece of the revenue cycle management processes in behavioral health billing. In this post we want to discuss items that will help obtain adequate insurance authorization for patients within your behavioral health facility.
One of the key aspects of pre-authorizations and utilization reviews is having well rounded masters level clinicians trained specifically in these processes. Clinicians are not trained in their masters program to manage insurance in any shape way or form. Unfortunately, this puts the majority of clinicians at a disadvantage for obtaining adequate authorizations for patients.
In order to assist with ensuring competency in your clinician you must have a specialized training program in place that will educate them on how to effectively obtain authorizations as well as continued stay reviews.
Have one of your clinicians dedicate time to reviewing and understanding patient placement criteria among the different insurance payers is a must. Keep in mind not all insurance carriers utilize ASAM placement criteria. You must familiarize yourself with the criteria and make sure you know the requirements prior to attempting to obtain authorization.
The most overlooked requirement in the authorization and utilization review process in behavioral health is the documentation. Many authorizations are done over the phone with the clinician treating the patient making the call to the insurance carrier and describing medical necessity to the care manager. You must document your patients case in great detail in order to provide a comprehensive picture that defines medical necessity for the specific patient. Without having adequate documentation you may be placed in a position in which you do not receive compensation for services or potentially receive more authorization denials lacking information.
This includes documenting detailed clinical and medical notes in the patients record. Insurance company care managers have a job to do with ensuring the patient in fact needs the level of care that is being proposed. If you do not have adequate information to build a case showing medical necessity you will experience and increase in authorization denials as well as claim denials after authorization is obtained.
Education and documentation are among the most problematic pieces to authorizing patients. Create proper policies and procedures within your behavioral health billing organization surrounding education and effective documentation.
If you would like to learn more about clinical documentation and education contact Elevated Billing Solutions 385-212-4004