by Mike Lardieri, LCSW on July 2, 2024
Revenue cycle management (RCM) is an essential part of running a behavioral health organization. Each step of the process, from pre-registration to claim submission and collection, affects the financial performance of providers offering mental health, IDD, and substance use disorder services.
Identify technology competencies that will best serve your behavioral health organization with our guide, The Ultimate Guide to Behavioral Health EHR Selection.
In recent years, as healthcare has increasingly adopted value-based payment, behavioral health RCM has become even more complex. Risk-based contracting requires providers to develop new competencies around adhering to quality-based measures, demonstrating improved outcomes, and assessing clinical performance at both the individual and population levels. Behavioral healthcare revenue cycle solutions tied to an EHR (electronic health record) can significantly aid in adapting to this new payment environment.
The ideal EHR must live in both worlds—fee for service and value-based payment—to protect the provider’s financial health for today and tomorrow.
What does this mean for behavioral health providers when examining the right technology for their organization?
Capabilities of Behavioral Health RCM Solutions for Billing
Under fee-for-service arrangements, the EHR for a behavioral health practice should streamline the billing and claims process, resulting in fewer denials and faster and complete payments. Revenue cycle optimization requires technology that will support and automate the following functions.
Accurate and complete charge capture
Accurate and complete charge capture is one of—if not the—most critical components for successful behavioral health RCM under fee-for-service contracts. Behavioral healthcare revenue cycle solutions should reduce the possibility of error in the charge capture process by assisting with documentation and coding. They also should be able to readily apply coding updates using rules-based processes, automate bill generation, and facilitate fast and complete claims submissions. Such efficiencies will improve the completeness of payments for the organization and the cost to collect.
EHRs should also have medication management and e-prescribing features that support more accurate billing, particularly mental health billing. These systems can standardize the creation of clear, thorough prescription records, which can help reduce documentation errors associated with handwritten prescriptions, like incorrect drug names and dosages.
Insurance Eligibility Verification and Prior Authorization
Behavioral health services often require prior authorization before they can be covered, which can add another layer of complexity to accurate and timely billing. Payers have their own rules about how many sessions they’ll pay for, the length of a session, and the maximum number of treatments. Verifying eligibility for service must be done accurately and quickly to ensure financial clearance for clients and supply accurate out-of-pocket estimates. Delays or inaccuracies can potentially disrupt client scheduling, result in claims denials, and contribute to bad debt. Seek a vendor that can provide electronic, real-time eligibility verification.
Easily Customize Collections
Along these lines, support for timely and accurate self-pay collections is also important. Behavioral healthcare revenue cycle solutions need to be able to integrate collection policies, administer payment plans, and facilitate self-pay collections with minimal manual intervention. Modern IDD, substance use disorder, and mental health billing software can help alleviate administrative burdens on providers. Using rule-based features, the right behavioral health billing solutions should customize financial statement setup, track payments to date, and ensure billing timeliness. In addition, solutions should allow for easy customization and updates to client statements.
Transitioning Behavioral Health RCM Strategy to Value-Based Payment
In addition to these traditional behavioral health RCM functions, it’s also important for technology to be able to assist with the new functionalities needed to adapt to value-based contracts. Practice administrators need confidence in the organization’s ability to abide by contractual terms, facilitate the sorts of clinical and financial workflow changes needed to be successful under agreed-upon metrics, and reliably predict performance. The following capabilities are true differentiators in this regard and can significantly affect an organization’s ability to adapt to payment change.
Customizable Alerts
One important feature to look for in a behavioral health RCM solution tied to an EHR is the ability to configure data capture and alerts. Pre-built alerts can help meet regulatory requirements, such as the Physician Quality Reporting Initiative (PQRI), as they notify providers that they need to complete associated data elements. The ability to configure similar requirements by the payer and automatically capture associated data will afford the organization the greatest flexibility in adapting to changing quality metrics over time. Technology capabilities in this area position the organization for the greatest success under value-based payment by maximizing the organization’s visibility of its performance and minimizing the amount of time and resources needed to verify and enter diverse and ever-changing data requirements.
Facilitating Effective Measurement-Based Care
Payment based on outcomes requires an accurate assessment of the client’s health before and after care and systems to ensure the care interventions pursued will adhere to best practices. As such, it’s important for behavioral health providers to have their clients’ complete records at the point of care and workflows that incorporate screening and assessment tools to effectively document changes in health status – or, for those receiving IDD services, their quality of life. Also important is steering toward evidence-based care planning and facilitating referral management. Each of these capabilities will help clinicians document progress and achieve quality targets most efficiently. Look for a system that allows the provider to securely send assessments to clients during their initial evaluation process, on a specified schedule, and on an ad hoc basis.
Risk-Based Modeling
Analytics and predictive capabilities are essential in behavioral healthcare revenue cycle solutions as the industry’s focus shifts toward tying together clinical outcomes and financial performance. Risk stratification relies on the ability to use historical data and machine learning algorithms to predict outcomes, estimate the probability of events, and forecast revenue based on various risk scenarios. Insights must also be drawn from this data to inform clinical decision-making and resource allocation. Population health management and understanding the impact of the social determinants of health (SDOH) have also become vital components of risk stratification, particularly in relation to tracking trends and managing care for high-risk groups. The importance of SDOH is, in part, evidenced by the Centers for Medicare and Medicaid Services (CMS)’s 2024 final rule addition of a new HCPCS billing code, covering an SDOH assessment as an optional element in annual wellness visits.
Preparing Your Behavioral Health RCM Strategy for the Future
Staying competitive in the market requires an RCM strategy that not only works for today but also adapts to the needs of tomorrow – including staying abreast of innovative artificial intelligence (AI) features in EHRs, like the ability to rapidly review new and changing rules before claims are completed.
Not having effective and up-to-date behavioral healthcare revenue cycle solutions tied to your EHR can lead to lost payment and slow cash flow because of missed charges or charge errors, claims denials, late payment, or ineffective billing and collections communications with clients. But perhaps even more importantly, it can result in the organization being left behind as the contracting environment continues to shift. As behavioral health organizations increasingly take on greater risk under value-based payment arrangements, behavioral health practice leaders need to ensure their technology is keeping pace.
Learn how Core Solutions’ Cx360 behavioral health EHR supports fast, successful billing for mental health, substance use disorder, and IDD services through easy scaling capabilities, the right training, and strong support. Schedule a demo today.
