Navigating payer rules in behavioral healthcare can feel like running a maze. These rules are more complicated than those for physical healthcare – they can feel downright intimidating. But understanding how to maintain compliance and bill properly is something that behavioral health clinicians and practice owners have to do. Failing to manage this part of your business well can result in lost revenue and delayed care for clients.

Fortunately, navigating complex rules is possible with the right strategies and the right supports in place. Read on to learn how your practice can keep up with the current rules and prepare for future changes.

Understanding Complex Payer Rules in Behavioral Health

The rules that payers set dictate how much and what type of information clinicians gather on patients, which billing codes to use, how to document treatment, and which treatments are covered. Every part of the billing process, front to back, is subject to these rules.

Here are a few common examples of complex payer rules, and how they differ from payer rules in physical healthcare.

• Not all payers cover the same treatments. Service coverage may be more nuanced and restrictive compared to physical healthcare coverage.
• More billing codes. The ICD-10 codes for mental health are more granular, including distinct codes for different subsets of diagnoses.
• Heavier documentation. Mental healthcare claims usually require more documentation than physical healthcare.
• Mental health parity laws. Parity laws have upped the expectations for documenting and justifying treatment. They also require payers to demonstrate how their mental health coverage is on par with general healthcare coverage. That requires capturing more information about patients, their conditions, and their treatment.
• The rules are in flux. Parity laws continue to change with ongoing legal and regulatory guidance. Behavioral health providers have to continually adapt.
• Prior authorization requirements. Mental health treatments are more likely to require prior authorization, adding another step before you can deliver care.

How Complex Payer Rules Can Affect Your Practice

Unfortunately, if you don’t understand these rules and how to manage them, they can negatively impact your practice.

Lower Revenue

Getting paid well for your services requires excellent coding, clean claims, and prompt responses to aging or rejected claims. Incorrect coding may cause you to leave money on the table and see a high number of rejected and denied claims. Few behavioral health practices have the time to easily manage large numbers of claims denials; inevitably, some fall through the cracks and never result in compensation.

Administrative Burden

Behavioral health practices juggle plenty of administrative tasks, between capturing patient information, documenting treatment, and billing. The more complex the payer rules, the heavier the administrative workload, and the fewer patients you have the bandwidth to treat.

Delayed Care

Prior authorization checks take time. If your practice doesn’t carry out the process efficiently, patients will be stuck waiting for treatment. Not only does this hurt those who urgently need help, but it may discourage some clients from getting help at all. If they feel that insurance coverage will be confusing, they may opt out of treatment rather than risk an unexpected bill.

How to Navigate Complex Payer Rules Like a Pro

Here’s how to be successful at handling your practice’s billing, even with complex payer rules.

• Proactively monitor changes to the rules. Remember, legal interpretations can shift and payers can adopt new strategies. Stay informed and be ready to adapt.
• Develop documentation processes. Staff and providers should have clear-cut steps to follow to capture relevant data. Without a common process, they’re more likely to make mistakes, and the quality of your documentation will vary.
• Train your staff on payer-specific requirements. Don’t assume they already know. Mistakes made in ignorance still cost money.
• Establish a pre-authorization workflow to obtain treatment authorization as quickly as possible.
• Use a behavioral health EHR for better compliance and speedier tasks.

Leveraging EHR Systems to Manage Complex Payer Rules

EHRs built for the challenges of behavioral health make it much easier to handle complicated, shifting payer rules. Blending functionality with ease of use, these systems create user-friendly and fast workflows for even the trickiest aspects of practice management.

To best navigate payer rules, you’ll need the following capabilities in your software:

1. Payer specific-templates. Customization options should allow you to create forms and templates that satisfy different payer requirements. For example, your providers may need to create payer-specific treatment plan templates, documentation templates, and billing templates.
2. Library of billing rules. Staff and providers need to easily reference the rules when they have questions.
3. Custom rule writing. This gives you the power to update your EHR with particular rules or to make changes as payer and legal regulations change. The more updated your EHR, the better the system can support you.
4. ICD-10 code library. This makes it easier to code accurately and comprehensively for all the services you provide.
5. Integrated billing. A billing system that pulls information directly from EHR records can eliminate many of the mistakes that come with manual data entry. Cleaner claims and fewer rejections allow you and your staff to recapture precious admin hours.
6. Strong reporting features for billing. You should regularly run reports on claims submissions, denials, payments, and aging claims. By keeping ahead of rejected and denied claims, you regain more revenue and fewer bills fall through the cracks.
7. Automated rule-checking features. Your software should be proactive in following rules and catching mistakes.
8. A worklist of charges. Make sure this feature can’t be auto-fixed.
9. Features to speed up documentation. Many EHRs now offer auto-generated narration and easy check-box options for creating progress notes. Paired with templates for each payer, this can tremendously enhance providers’ ability to meet all payer requirements without getting bogged down in hours of documentation.

Best Practices for Compliance and Reimbursement

Great software by itself won’t secure success. It’s crucial to establish best practices for compliance and stick to them consistently.

Start by deciding on a regular cadence of billing audits. As mental health payer rules continue to change, audits help reveal where you need to adapt. They can alert you when rejection and denial rates are creeping up, allowing you to troubleshoot problems before they substantially affect your revenue. For prompt adjustments to complicated rules, regular audits are a must.

Second, build relationships with payer representatives. These expert voices can interpret confusing rules and partner with you to address problems with your claims, so foster goodwill with them. Reach out when you have questions and thank them for their help.

Third, take advantage of other resources. If you have access to a payer portal, you can likely find information there about compliance and payer rules. Reach out to industry associations for news, updates, and their suggested best practices. Check into training offered by your EHR provider; these trainings may be able to help your staff get the most out of billing features and better understand the nuances of compliance.

The Future of Payer Rules in Behavioral Health

Adaptation will always be the name of the game. Payer rules and billing requirements will continue to change. Policy regulations, such as the parity law, will continue to present new requirements. And, fortunately, technology will continue to find fast and efficient ways to deal with the complexity.

The habits you build today to navigate complex rules will serve you when change inevitably comes. Stay abreast of updates, create smart processes for compliance and billing, and lean on behavioral health specific EHRs to ease your administrative burdens.