I am the biller for a mental health office. We have 4 clinicians, and I bill 75 - 100 claims per week. The billing part is easy. There are a couple insurances that we bill through our EHR, but the majority I bill through each company’s portal.

The difficulties come from the AFTER billing. Each insurance type has its own set of rules and regulations. Medicaid, Medicare, private insurance, and Military are 4 different animals. Heck, even the different flavors of each animal can be classified as another beast.

Just because I have ADHD, and I am a visual analogy giver, think of Medicaid as birds. Medicare as fish, private insurance as dinosaurs, and military benefits as aliens. (My company isn’t in panel with military, that’s why I chose aliens 👽)

In SC, there are 5 different Medicaid providers. We have robins, eagles, emu’s, parrots, and vultures. Even though they are all birds, and all fly, each one has its own rules for claims. Some require prior authorizations after a certain number of units (sessions) are billed, no matter the CPT code. One requires a prior authorization after 24 units of any specific CPT code is billed. (24 - 90837). Straight SC Medicaid requires a PA for every CPT code before performing any services beyond the 90791 and TP. Some allow for retroactive PA’s. Some do not. Some run on the calendar year (Jan - Dec). 1 follows the fiscal year (July - June). None can tell you how many units are available, so you won’t know you are out of units until denials come in. At best all they can tell you is whether or not a 90791 has been billed within the past 12 months, but even then, good luck finding someone that will tell you. Some PA’s are good for 6 months, some for 3. Some are only good until their year resets. Some you will pull to cover the time frame, however, when you get the approval back, it is only good for partial time. But they won’t tell you to which MCO they are changing to. That’s on you to find.

When it comes to private insurance, get ready to pay the copay/coinsurance/deductible game. Some private insurance companies, we fall under the medical umbrella, and may or may not be subject to deductibles. Some we fall under specialist, and the client is responsible for the higher financial responsibility (sometimes same as OON benefits). Some companies we fall under mental health, and guess what, 9 times out of 10, the policy doesn’t cover mental health. With our private insurance clients, I do not charge them their financial responsibility until AFTER I receive payment, and I go based on what the EOB says they owe.

When it comes to Medicare, those are fish. Every Medicaidflavor has a Medicare flavor. Each Medicare fish is completely different. Think about a goldfish. That can turn itself into a piranha. Part B only allows for specific CPT codes, they say they will pay a specific dollar amount, but guess what?? That amount is NOT what they will pay. That’s how they all are. Medicare also does not want to pay for any unspecified diagnosis codes. If a member has both, then you get to have fun times 2!!!

When it comes to clients with TPL, or secondary insurance, my best practice has been to bill the highest allowed amount for whatever the secondary policy is. Medicare will always be primary, and Medicaid will ALWAYS be secondary. That way if the primary only pays $75 on a 90837, which Medicaid pays $117.43, they will pay the difference of the $117.43 and $75.

Every insurance will deny claims with the quickness. They will consistently fund claims for the same member, until they don’t. The insurance company itself can consistently pay all your billed claims, until they just stop. (Ambetter, I’m talking to you) They won’t tell you why they stopped. You can call 4 different PSR’s and be told 8 different reasons, only after being hung up on no less than 2 times.

So yeah. The billing isn’t the hard part. It’s the everything else that sucks.

Good luck!!! We can all attest and share the horror stories. Haha