or How to Check Benefits Without Losing Your Mind

 

Patients don’t like to get a bill for services they thought would be covered by their insurance. And you don’t want to write off patient responsibility you thought insurance would cover. But these are the common results when patients are seen before verifying mental health benefits. If you do your own billing or you work with a biller who doesn’t check benefits, use this guide to empower yourself and avoid surprises.

Step 1. Gather Essential Patient Information Early

Before contacting the insurance company, collect the following demographic and other details to streamline the process for verifying mental health benefits:

  • Full Name (as listed on the insurance card)
  • Date of Birth
  • Insurance ID and Group Number
  • Primary Policyholder’s Information (if different from the patient)
  • Insurance’s Customer Service Phone Number (typically on the back of the card)
  • Reason for Visit: This helps ensure you verify for the correct service (e.g., outpatient mental health).
  • Other coverage. You need to know about all behavioral health plans related to the service you provide. You must submit claims to the primary payer first, even if there’s no coverage.

Pro Tip: Use digital intake forms that allow patients to upload their insurance cards directly, reducing administrative burden and transposition errors.

Caution: Dealing with secondary coverage and coordination of benefits (COB) can be frustrating, especially when the plans are not coordinated properly. The patient will need to be involved if this is the case.

Step 2. Contact the Insurance Company

Create a benefits verification script to ensure nothing is overlooked when you’re verifying mental health benefits. 

Key Questions Include:

  • Effective date of the policy?
  • What are the outpatient mental health benefits? This is the deductible, copay/coinsurance, and out of pocket amount.
  • Has the deductible been met for the year? If not, what amount remains?
  • Is prior authorization or PCP referral required for the service? If so, how do you get one?
  • Are there session limits? (e.g., 20 therapy visits per year)
  • If applicable to your practice, are benefits the same for therapy (90834, 90833, 90836, 90837, etc) as for office visit codes (E/M codes like 99203, 99214)?
  • Is telehealth or virtual therapy covered under this plan? If so, do they have the same benefits?
  • Is there any coordination of benefits on file? If so, what insurance company is the other plan and in what position is it (primary or secondary)?
  • What’s the claims mailing address and payer ID number?

Pro Tip: Use insurance portals (e.g., Availity or payer-specific portals) to verify benefits online. But be cautious: it can take time to master each portal and learn what information is trustworthy and what is not.  

Pro Tip: Create a reference document to easily access your practice information. You will be asked for a few identifying details like your NPI, TIN, name, business address, call back number, etc. This is also a great place to note which networks you are contracted with and any payer specific identifiers (like your Medicare PTAN).

Step 3. Maintain a Tracking System for Calls When Verifying Mental Health Benefits

  • Create a Log or Tracker: Use a spreadsheet or CRM tool to document insurance verifications.
  • Essential Columns to Track:
    • Date and Time of Call
    • Insurance Representative’s Name
    • Confirmation Number (if they can generate one)
    • Notes on Coverage, Co-pay, and Limits

Pro Tip: You can automate some of this with practice management software that includes a verification module (e.g., SimplePractice, TheraNest).

Step 4. Educate Patients on Their Benefits

Help patients understand their financial responsibility and coverage limitations. Clear communication prevents surprise bills and promotes trust.

  • Provide a Summary of Benefits: Offer patients a written summary after verification.
  • Clarify Copays and Deductibles: Explain what will be charged per session and what they need to pay out-of-pocket if the deductible isn’t met. Make sure patients understand you verified the benefits to the best of your ability, but if you misunderstood something or were misquoted, they may still owe more than you’re estimating.
  • Set Expectations Around Session Limits: Alert patients to limits on covered visits and discuss payment options if additional sessions are needed.

Pro Tip: Offer insurance education sheets in your office or via email to help patients understand key terms (deductible, co-insurance, etc.).

Pro Tip: Create a chart of contract amounts for each company you’re contracted with. This can help you estimate coinsurance as well as how many sessions it could take to meet the deductible. 

Step 5. Verifying Benefits Regularly

  • Ask patients about new coverage annually and after long gaps in treatment. If a patient has a new plan, check coverage again.

Step 6. Troubleshoot Problems When Verifying Mental Health Benefits

  • Problem: Insurance Says Patient is “Not Covered.”
    • Solution: Confirm you’re using the patient demographic details you were given. If that still doesn’t work, communicate with the patient to clarify the details and/or inform them they don’t seem to have coverage to work with you. Explore the opportunity to see them on a cash pay basis.
  • Problem: Coverage for Telehealth is Unclear.
    • Solution: Confirm the CPT codes for telehealth services and ask if modifiers (like GT or 95) are needed to indicate virtual care.
  • Problem: Authorization is Required but Not Obtained.
    • Solution: Call for retroactive authorization and document all communication to support appeals if the claim is denied.

Step 7. Automate and Outsource When Possible

  • Automate Verification: Many practice management systems integrate with insurance portals to automatically verify benefits at regular intervals.
  • Consider Outsourcing: For busy practices, outsourcing insurance verification to a billing company can save time and reduce errors. We know an excellent billing company!

Step 8. Create a Standard Operating Procedure (SOP) for Staff

  • Document the Process: Outline step-by-step instructions for verifying benefits.
  • Train Staff: Regularly train administrative staff on insurance verification best practices.
  • Assign Responsibility: Designate a team member to handle all verifications to ensure consistency.

Step 9. Monitor Trends in Coverage and Adjust Services Accordingly

  • Keep track of common insurance denials and coverage limitations over time. Use this feedback to improve your billing practices to submit clean claims that sail through the claims adjudication process effectively.
  • Adjust your practice’s service offerings and policies to align with these trends (e.g., focus more on telehealth if in-person sessions face more restrictions).

With a strong process in place for verifying mental health benefits, you can reduce billing errors, improve patient satisfaction, and increase cash flow. 

If you’re stuck, confused, and or frustrated doing your own billing, reach out today for a consultation. You’re ready to outsource your billing to a trusted billing company, reach out to us to request a Discovery Call to see if we have an opening to take on your billing.

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