Where most billing companies provide only a basic verification of benefits, we provide a full benefit analysis. First, we deliver a baseline description of coverage to give your facility an idea of what to expect in terms of reimbursement. This preliminary information includes member responsibility, maximums, and plan-specific information regarding coverage.

To give you a more complete idea of what coverage will look like, we utilize our database of provider knowledge and plan-specific payment history so you get a realistic idea of what to expect when your client remits.

Part I: Verification of Benefits

Our Verification Specialists will provide you with the following information:

• Patient policy deductibles and out-of-pocket responsibility (member responsibility)
• Co-insurance and administrative co-payments
• Benefit limits and policy maximums
• Reimbursement estimates
• Pre-authorization and clinical requirements for admissions

Part II: Medical Necessity Analysis

We go farther than other billing companies by providing an estimate of authorization potential, based on a clinical snapshot provided by your facility. By using the data we gather, we can more accurately gauge the actual return from a carrier for a client that you’ve admitted.

What is Utilization Review?

Utilization review (UR) is the process insurance companies use to approve, authorize, or decline services. The utilization review process is designed to screen and approve the “least-restrictive” clinical services on a per–case basis. Insurance carriers use this process to standardize approval criteria so they only pay for services deemed medically necessary. Also, utilization review helps prevent fraud, abuse, and wasting funds on unneeded services.

How important is utilization review to my company?

Any behavioral healthcare organization that works with insurance should realize that utilization review is one of the most critical aspects of obtaining payment. Quality utilization review and management is the starting point from which the financial health of a healthcare organization is derived.  Often overlooked or disregarded, improper and/or poorly managed utilization review limits profitability, a client’s length of treatment, and their access to it.

Utilization Review training and development for your staff

We believe that no one can fight harder for your clients and their families than your own staff. Your facility’s staff has first-hand knowledge of your clients’ clinical cases, ongoing struggles, successes, long-term treatment goals and plans, and symptoms that meet medical necessity criteria. Because of this, we offer our depth of experience to assist you with in-house hiring, training, and/or development of top-notch Utilization Review professionals from within your current staff.

Outsourced Utilization Review and Management

If your facility is unable to offer in-house utilization review, we offer an outsourced solution for your UR needs. We surpass our competitors by focusing on communication with facilities intake/admissions teams to develop a full medical and clinical picture of a client’s case prior to intake and upon it.  Upon intake, our Utilization Review team can frame the best argument for each and every client. Our level of service and attention to detail is unparalleled in the industry.

Understanding Denials

Medical Necessity

One of the most common denials in behavioral healthcare is a medical necessity denial, which occurs in almost every case of substance use treatment. Carriers use medical-based criteria to decide if a client’s care can be authorized. If a client doesn’t meet specified criteria, the carrier will deny the claim for lack of medical necessity.

Processing Denials

Some denials aren’t the fault of the provider or submitting entity. Carriers often deny claims “in error” simply to delay payment.

Timely Filing

Plans typically provide time frames when claims must be submitted. If you don’t meet these time frames, you must file an appeal.

Appeals

When a Claim Is Denied

If a claim is denied, the provider or client can appeal the decision. These appeals take time to process, but they can be won if the correct procedures are followed. We differentiate ourselves from other billing companies by relentlessly pursuing payment on denials and appeals until our clients receive what they’re due.

We optimize your intake and administrative processes.

• You receive a comprehensive analysis of your intake and billing process.
• We correct your facility’s processes and procedures.
• We develop air-tight operating systems to support a healthy revenue cycle.

We train and develop your staff.

• We properly train you staff in the revenue cycle so they learn what’s required of their departments.
• We improve quality of care.
• We increase your profitability.