Behavioral Health

Ask the Experts: Behavioral Health Revenue Cycle

August 9, 2016 1:45 pm

Can you explain the significant differences and challenges inherent in behavioral health revenue cycle?

Answer 1: My answer pertains to situations where behavioral health is a fairly small program within your hospital. Our issues stem from the fact that the health plans we contract with tend to carve out the behavioral health piece to other entities. Because we don’t have direct contracts with those entities, we have difficulties with the claim processing and relationship. Although our primary contracts have language for handling these claims, we have issues with every aspect of the process. Preauthorizations are difficult, payments are unpredictable, and setting expectations for these very vulnerable patients is particularly difficult.

This question was answered by: Ruth Landé is vice president, patient revenues, Memorial Sloan-Kettering Cancer Center and a member of HFMA’s New York Metropolitan Chapter.

Answer 2: The major issues I have dealt with regarding behavioral health revenue cycle are managing HMOs that subcontract behavioral health services, credentialing of clinicians (physicians and licensed clinical social workers), and managing authorizations.

This question was answered by: Caswell Samms is network CFO, Lincoln Medical Center and Harlem Hospital.

Answer 3: I agree with the above response.

Also, in some hospitals and health systems that provide both medical and behavioral services, behavioral services get less revenue cycle attention than it should on a proportional basis. One reason is that a large percentage of revenue cycle professionals have more experience with medical services, so they do not have the tools or interest to effectively manage behavioral revenue cycle work.

A second reason is that behavioral services comprise a smaller percentage of revenue for many providers, with smaller charges for individual cases for inpatient and outpatient care. As a result, extremely significant amount of revenue cycle time may be devoted to medical revenue issues where individual cases represent large dollar amounts.

Third, behavioral services for a given patient often can have a different payer than the payer for that patient’s medical services. In such cases, bills can be sent to the wrong payer if staff are not aware of this difference.

Some health plans outsource their behavioral payment work to contractor companies, and some of these companies become the payers instead of the health plans. The contractor companies may have arcane rules with regard to billing and payment. The results can be frequent denials for payment, especially for inpatient behavioral care.

Appeals of denials for behavioral services can require a provider to jump through many hoops compared to denials for medical care. This can be especially true when contractor companies are the actual payers.

Some hospitals treat behavioral services as a “hospital within a hospital” in order to have proper attention paid to the behavioral services revenue cycle. In those cases, the behavioral services “hospital” has its own revenue cycle team. The medical and behavioral revenue cycle teams schedule meetings to discuss patients who are receiving both types of services. A frequent topic is bills for behavioral health services that were incorrectly sent to their medical payer.

This question was answered by: Robert J. Ellertsen, FHFMA, is a former hospital CFO with more than 35 years of experience in healthcare finance and a member of HFMA’s Massachusetts-Rhode Island Chapter.

What do you think? Please share your thoughts on this question in the comments section below.  

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