MANAGED CARE RESOURCES

Introduction For many behavioral health organizations, commercial managed care contracting feels like a necessary step toward growth and sustainability. But here’s the reality:Most organizations don’t lose money because of bad contracts—they lose money because they’re not operationally prepared to perform under them. Contracting is not just a legal or financial exercise. It’s an organizational commitment [...]

In our previous article, we discussed the differences between Traditional Medicare and Medicare Advantage and why behavioral health organizations cannot assume that all insurance products follow the same reimbursement rules. One of the most common questions we receive from behavioral health practices involves supervision and billing. The question usually sounds something like this: A Common [...]

As behavioral health organizations expand services and add prescribing providers, we continue to hear a common question from the field: A Common Question "Our Nurse Practitioner is individually enrolled with Medicare and actively seeing Medicare beneficiaries. Why are our Medicare claims still denying?" The answer often surprises practice owners, executives, and billing teams. Simply having [...]

From time to time, we come across questions from the field that we know affect all behavioral health practices.   We’re seeing a growing number of practices run into this issue as they expand services and staffing models: Q: I have Licensed Social Workers (LSWs) in my practice who see commercial clients under my supervision, and [...]

For many years, community behavioral health organizations primarily focused on two funding sources: Medicaid and local Mental Health Board funding. The billing rules were relatively straightforward. Agencies understood what services were covered, who could provide those services, and how reimbursement worked. Today's environment is very different. Behavioral health providers now navigate a complex payer landscape [...]

From time to time, we receive questions from the field that we know impact many behavioral health provider groups.  We recently received the following question from a behavioral health provider: "Our organization offers a chemical dependency IOP program and has several clients covered by commercial insurance plans. We verify benefits, obtain authorizations, and provide the services. [...]

An Intensive Outpatient Program can be fully operational, properly authorized, and billing claims correctly—and still be underpaid. For many behavioral health organizations, the problem isn't the revenue cycle. When this happens, the first assumption is often that there is a problem within the revenue cycle. Claims are reviewed. Billing workflows are examined. Coding is audited.  [...]

Why Product Line Verification Matters More Than Ever One of the most common questions we hear from behavioral health organizations is: "Are we in-network with this payer's product?" It sounds like a simple question. Unfortunately, the answer isn't always simple—and assuming you know the answer can become an expensive mistake. We've worked with organizations that [...]

One of the most common mistakes organizations make is treating commercial insurance like an extension of Medicaid. It’s not. Medicaid typically offers: Broader service coverage More predictable reimbursement Minimal patient financial responsibility Commercial insurance, on the other hand: Covers a narrower set of services Varies significantly by plan and product line Shifts a large portion [...]

This question has been perplexing private practice clinicians for the last couple of years: “Why does it feel like we’re doing more work — but getting paid less from commercial insurance?” When I talk to clinicians trying to unpack this, I usually go through my punch list: Has your overall client volume changed from the [...]