Are healthcare organizations prepared to handle this drastic influx? In a lot of cases, no.
Most revenue cycle management (RCM) systems are designed for general healthcare settings and not the specialized needs of behavioral health. As a result, when these systems are adopted by behavioral health organizations, they often fall short in handling the unique complexities of behavioral health billing.
Technologies with specific behavioral health RCM capabilities, however, can help facilities avoid time-consuming and costly errors as well as inefficiencies and the need for more manual labor. By working with an experienced partner with an advanced electronic health record (EHR), behavioral health organizations can achieve cleaner claims, timelier reimbursement, and improved compliance, all in service of a better bottom line.
Compared to revenue cycle management in general healthcare practices, behavioral health RCM is distinctly complex. RCM professionals in behavioral health often navigate more diverse service delivery models; a wider range of provider specialties; complex, payer-specific coding guidelines; and continuously evolving compliance requirements.
Manually handling these demands not only requires significant time and resources, but doing so can also lead to problems that threaten organizations’ financial sustainability. Here’s a look at six of the biggest challenges in behavioral health RCM and how the right partner with the right EHR can help organizations better address them.
All healthcare practices must follow medical coding requirements to properly bill and receive payment for services delivered. Staff must apply the correct codes that align with services rendered to facilitate a smooth, fast, and accurate billing process.
(This is particularly challenging in the behavioral healthcare space, as coding for behavioral health involves a plethora of services — from prevention to diagnosis to treatment and intervention — and each requires its own specific codes. Coders in behavioral health RCM must understand standard ICD-10 medical codes (which represent diagnoses), Current Procedural Terminology (CPT) codes that represent the services performed, and Healthcare Common Procedure Coding System (HCPCS) codes, which cover services, products, and supplies not covered by CPT codes, such as ambulance services or medications. Each of these coding standards include multiple categories based on where and how the services are delivered.
CPT codes account for integrated care models and include specific coding nuances for time-based and add-on services. Things like group therapy or occupational therapy also come with specific requirements that make coding for behavioral health particularly challenging.
EHRs with integrated behavioral health RCM capabilities automatically assess assigned codes according to customized checks before claims are submitted. This reduces administrative burden while reducing coding errors that could lead to payment delays and denials.
Since behavioral healthcare providers are increasingly embracing whole-person care, they’re more often collaborating with other professionals, such as psychiatrists, case managers, and in-home caregivers.
This integrated care approach helps ensure that different providers work in tandem to address the overlapping mental, emotional, and physical needs of their clients — but it also adds complexity to already complicated insurance processes. Accounting for varied service settings, such as group therapy or telehealth, can make insurance verification even more challenging.
Behavioral health RCM features in advanced EHRs enable teams to define payer-specific rules and workflows, better ensuring verification procedures align with the unique needs of the state, insurer, and health plan.
In 2023 alone, 19% of in-network claims and 37% of out-of-network claims were denied by insurers of qualified health plans, according to KFF research. In behavioral healthcare, denials tend to be even more common, largely due to common problems like:
Due to the complicated nature of behavioral healthcare delivery, insurance plans often limit coverage for these services or require preauthorization. These conditions are why 22% of individuals who sought mental healthcare in 2023 were denied coverage, according to KFF.
EHRs with embedded behavioral health RCM engines take much of the guesswork out of insurance verification. Custom-built workflows and insurer integrations enable teams to get real-time access to clients’ insurance details, while eligibility checks significantly minimize denials and workflow bottlenecks.
In the U.S., Medicaid is the largest payer for mental healthcare services. Medicaid has historically ensured that millions of Americans receive adequate coverage for behavioral healthcare services, particularly with the addition of the Mental Health Parity and Addiction Equity Act, which established additional coverage criteria and adjusted copays, coinsurance, and out-of-pocket fees.
Yet, recent federal legislation includes various changes to Medicaid coverage practices that organizations must account for now and down the road. And because Medicaid has different billing requirements than most commercial insurers, these changes are making navigating payer nuances even more challenging.
The right behavioral health EHR will offer tailored workflows and payer-specific rules to help ensure all claim submissions align with each insurer’s requirements. This capability helps relieve staff of the burdensome task of manually keeping pace with payer requirement changes and aligning claims to payer-specific needs.
In 2023, the U.S. Department of Health and Human Services launched one of the most comprehensive compliance guidance efforts to date. But that wasn’t the only — or the last — change to regulatory or compliance requirements. Changes to HIPAA regulations, for example, happen frequently, requiring behavioral health organizations to regularly review their protocols to ensure compliance.
Organizations must meet state-specific mandates, as well as federal and service-specific regulatory requirements, and an EHR with behavioral health RCM capabilities can help ensure compliance with much of it. The right EHR offers embedded compliance trackers to help leadership and staff better ensure all regulatory tasks are completed and deadlines are met.
While provider turnover and retention are issues in nearly all healthcare specialties, they’re pervasive in behavioral health. More than 122 million individuals in the U.S. live in a mental health provider shortage area, 60% of psychologists aren’t able to accept new patients, and individuals must wait an average of 48 days to see a provider, according to an HRSA report
These statistics indicate that not only are clients not receiving the services they need, but also that organizations are struggling to retain and license the staff needed to meet increasing demand.
By taking administrative burden off the workforce, an advanced EHR can help retain providers and staff, ensuring the time needed for behavioral health credentialing doesn't impact organizations as drastically. Behavioral health RCM capabilities automate much of the billing, reimbursement, and insurance verification processes, further freeing up staff to focus on client care.
The behavioral healthcare market may be growing rapidly, but generating consistent, stable revenue is far from a given for all organizations, not only because of the above challenges in behavioral health RCM, but also because changes in Medicaid eligibility and coverage could impact patient access, particularly in rural areas, and affect the financial stability of some facilities.
It’s therefore critical that organizations intelligently leverage their time and resources, and they consider the negative impact that manually handling compliance, billing, reimbursement, and overall revenue cycle management can have on cash flow.
With a top behavioral health EHR like Core Solutions’ Cx360 platform, organizations can fast-track their revenue cycle management and ensure more accurate and seamless processes. Cx360 offers must-have features like:
Cx360 is an all-in-one platform that behavioral health organizations nationwide are relying on to manage their revenue cycle more effectively and help ensure accurate, timely payments and collections. Learn more about Core Solutions’ dynamic EHR and its advanced RCM capabilities.