The Behavioral health practice was burdened by multiple administrative challenges and their patient billing and revenue was affected. We understand the complexity of behavioral health billing, we know that lack of alignment between clinical coding and payer requirements, led to poor cash flow and increases claim denials.
Client Profile:
- Provider: Family Psychiatric Mental Health Nurse Practitioner
- Specialty: Behavioral Health
- Billing Portals: Medicare, Medicaid, Fidelis, Availity, UHC
- State: New York
Identified Challenges
Upon onboarding, our team conducted a thorough audit of the provider’s revenue cycle. The following core issues were identified:
- Incorrect Taxonomy Setup
The taxonomy code linked to the NPI did not reflect the behavioral health specialty, causing automatic rejections from Medicaid, UHC, and Medicare portals. - Inconsistent and Non-Specific Coding
The coding system lacked behavioral health-specific codes and used generic E/M codes that didn’t match payer requirements. ICD-10 coding was either vague or incomplete. - Provider Enrollment Gaps
The provider’s enrollment status with Medicare, Medicaid, and commercial portals (Fidelis, Availity, UHC) was either inactive, outdated, or submitted with mismatched information (TIN/NPI/Taxonomy mismatch). - Claim Submission Gaps
Claims were inconsistently submitted, often without required documentation or with missing authorizations. - Authorization & Eligibility Checks
There was no system in place to verify patient eligibility or ensure prior authorizations, leading to unnecessary claim denials and patient billing issues.
Solutions Implemented by One O’Seven RCM
We deployed a multi-phase action plan tailored to the behavioral health specialty and compliant with major payer portals.
1. Taxonomy Correction and NPPES Update
We corrected the taxonomy code with NPPES and updated it with all portals including Availity, UHC, Medicaid, and Medicare. This allowed proper alignment with behavioral health-specific services and improved provider recognition.
2. Coding Revision and Staff Training
A certified coding team introduced CPT and ICD-10 codes specifically for behavioral and mental health services. Frequent sessions were conducted with the provider and staff for accurate chart documentation.
3. Enrollment Management
We re-initiated enrollment for all necessary plans with corrected data. Specific attention was paid to:
- Medicare PECOS updates
- Medicaid re-validation
- Commercial payer contracts via Fidelis and Availity
- CAQH updates for UHC contracting
Turnaround time for updated enrollments averaged 15–45 days per payer.
4. Eligibility & Authorization Workflow
We integrated a weekly eligibility verification process and implemented prior authorization workflows for time-sensitive behavioral procedures. Portals like Availity were used to track approvals and provide documentation with each claim.
5. Charge Entry and Claim Scrubbing
We assigned a dedicated charge entry specialist who ensured accurate coding, modifiers, and charge mapping. All claims were scrubbed before submission using our in-house system to catch errors proactively.
6. Aggressive Denial Management & AR Follow-Up
Our AR follow-up specialist monitored rejections and followed up with each payer within 3-5 business days. All denied claims were appealed with proper documentation and success rate improved by 82%.
7. Reporting & Provider Communication
We provided weekly billing summaries, denial trends, and revenue dashboards to the provider for full transparency.
Results Achieved in one year
- Revenue Increase: From $35,000 to $125,000/month
- Claim Acceptance Rate: Improved from 65% to 96%
- Enrollment Completion: Medicare, Medicaid, UHC, Availity, and Fidelis active
- Coding Accuracy: Over 92% based on audit checks
- Denial Reduction: Denials reduces by 70%
- Faster Reimbursements: The average reimbursement time reduced from 45 to 18 days
- Cash Flow Accelerated: Faster payments and fewer denials improved financial health of behavioral health practice.
- Operational Overhaul: Staff time freed from chasing claims; focus returned to patient care.
Key Learnings
- Accuracy in Taxonomy Matters
Systems like Medicare and Medicaid depend on exact taxonomy. Mismatches caused routine denials. - Behavioral Health Coding Is Specialized
Nuances in therapy codes and session documentation demand expert coding oversight. - Enrollment Must Be Maintained
Even small lapses or outdated provider credentials can disrupt billing pipelines. - Denials Are Recoverable
With focused follow-up and AR teams, many denied claims were appealed and paid.
Conclusion
Within a year, One O’Seven RCM transformed this practice from $35K/month to $125K/month. With targeted interventions across taxonomy, coding, enrollment, and denial systems, what seemed like a plateau in revenue became clear, measurable growth. If your clinic is struggling with coding accuracy, payer enrollment, denials, or taxonomy errors, especially in behavioral health.