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Blogs February 16, 2022

How Do Benefits Get Verified in Behavioral Health?

When an individual chooses to receive treatment at a behavioral healthcare facility, they must first go through the admissions process, during which insurance benefits must be verified to determine whether they will need to pay out of pocket or if their services will be covered entirely. Verifying benefits in behavioral health is crucial, and an integrated CRM, EMR, and RCM system can help make this process easier. 

The First Step: Getting Insurance Information

When an individual calls the admissions line and expresses interest in a behavioral healthcare facility, an admissions representative will need their insurance information. This often includes the insurance company, member ID, group number, subscriber name, and subscriber date of birth. Some admissions staff may also ask for a picture of the front and back of the insurance card along with a picture of the subscriber’s ID. 

Verifying Benefits With an Insurance Company

Once this information is obtained, the admissions representative or the utilization review (UR) department will call or use online services to verify the patient’s insurance benefits. The staff member will either contact or use the website for the specific insurance provider and share the information the individual wishing to verify benefits gave them. 

From there, the insurance company will help the admissions or UR staff determine if the policy is active and other details such as if it is an employer or exchange policy. They will also verify who handles the claims and that the staff has the correct billing and pre-certification (pre-cert) information on file. The insurance company will also let staff know if there are out-of-state benefits or any restrictions or exclusions on the policy. Most importantly, admissions or UR staff will obtain the deductible amount, co-insurance, co-pay amounts, and maximum out-of-pocket costs. 

Breaking Down Deductibles, Co-Insurance, Co-Pay, and Maximum Out-of-Pocket

Deductibles, co-insurance, co-pay, and maximum out-of-pocket costs are some of the most crucial pieces of information for the behavioral healthcare facility and the individuals wishing to verify their benefits. A deductible is the amount of money a patient must pay a facility before insurance pays any claims. This amount of money typically must be obtained before treatment can begin. 

Co-insurance refers to the percentage of the cost the patient will be responsible for to receive treatment. For example, insurance may cover 50% of treatment, meaning the patient will be responsible for the other 50% of costs. Depending on the policy, co-insurance can range anywhere from 50%/50% to 100%/0%. 

Co-pay, or co-payment, is the amount of money an individual has to pay at the start of each service rendered if a co-pay is required for the policy. Not every policy requires a co-pay for individuals to attend behavioral healthcare facilities. The most significant difference between a deductible and co-pay is once an individual meets their deductible for the calendar year, they will not have to pay it again if they attend another facility or require more services. However, a co-pay will need to be paid every time services are required. 

An individual’s maximum out-of-pocket is the total cost of treatment they will be responsible for. Typically, any deductibles, co-insurance, and co-pays apply to the out-of-pocket maximum on most policies. For example, if an individual’s co-insurance is 80%/20%, they will only have to pay 20% of treatment costs up to their maximum out-of-pocket capacity. Once they reach this capacity, insurance pays 100%. 

The Importance of an Integrated System

When a behavioral healthcare facility’s system is fully integrated with Customer Relation Management (CRM), Electronic Medical Records (EMR), and Revenue Cycle Management (RCM), the process of verifying benefits is made more accessible. The information collected during the admissions process for verification is entered into the CRM software. From there, this data is automatically carried over into the EMR and RCM software, eliminating the need to enter data across multiple platforms. Having CRM, EMR, and RCM systems integrated into one database allows single-point data entry and easy access, real-time data for system users, management, and administration to reference at any time. The information seamlessly flows from patient intake to multiple points within the workflow for maximum accuracy, data integrity, and efficiency.

Once this information is passed into the EMR system, staff can access it as needed with patients. For example, if a patient needs to pick up a prescription at a pharmacy, staff can use their insurance information to get their prescription costs covered. 

Having this information in the RCM system allows an easy and streamlined billing process to occur. With our RCM fully integrated within the EMR, information collected across the board is converted to one location, allowing for auto-generated charges, easy-to-perform billing audits, and patient billing.

The first step in receiving care at a behavioral healthcare facility is insurance benefits verification. During this process, an admissions representative will obtain the necessary information to relay. From there, admissions staff or the utilization review department will use that data to get the information required for billing and payment. With a fully integrated CRM, EMR, and RCM software system, the process of verifying benefits can be made more accessible for all staff at a behavioral healthcare facility.

At Lightning Step Technologies, we seamlessly integrate CRM, EMR, and RCM software into one platform, effectively helping facilities bring a patient through admissions all the way to discharge. We aim to make things as easy as possible for our clients through our unique software system to maintain an efficient workflow and uphold a positive reputation. For more information about how Lighting Step Technologies’ innovative software program can help your facility with insurance verification and billing, schedule a demo today!



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