1. Inability to obtain Pre-Certifications
Pre-Certification is “Difficult” and often impossible, without the cooperation of the clinical and medical team of the addiction treatment provider. Insurance companies will deny admission or limit status as “Pending” (typically 15 days or longer) if a client’s information is lacking criteria to meet medical necessity, lacking a diagnosis, missing information on the client’s drug use history, missing vital sign, medical and mental status, and other pertinent information. Lack of adequate information will interrupt your billing cycle before it has begun.
2. Inability to obtain continued authorizations for concurrent reviews
Authorization is “Difficult” and often impossible for Concurrent Reviews, unless the client’s chart is accurate and continues to meet criteria relevant to the client’s level of care. Insurance company’s requirements include but are not limited to: All assessments including a completed Biopsychosocial and Initial Psychiatric Evaluation, Doctor’s Orders, Evolving Treatment Plans, Current Clinical Notes, Family Contact, Continued Medical Necessity, and more. Client charts without the required information will interrupt your billing cycle and your reimbursements.
Important tips to remember
Upon admission, ALL patients must meet medical necessity as defined by DSM 5 and ASAM. All treatment centers are required to complete all necessary admission documentation for medical necessity “as well as” the required admission paperwork as defined or required by the insurance payer source, the licensing and credentialing bodies for your state and county, the DSM 5, and the ASAM criteria, set forth as guidelines for medical necessity, diagnosis, levels of care, and appropriate services for patients/clients.
Such information includes:
- Completed, Accurate, and Current Verification of Benefits
- Appropriate admission documents and releases
- Admission Assessment including history of drug use and prior treatment
- Initial Psychiatric Evaluation
- History and Physical
- Vital Signs
- Initial and Master Treatment Plans
- Current and Accurate Clinical Notes
- Family Involvement
- Doctors Orders and corresponding care and medication (if ordered)
Stay tuned for more information and tips on medical billing. Feel free to also check out Urgent Medical Billing or call 800 -868 -8772 for billing done right.