Medical Billing for Therapists: Why Claims are Denied (reason 11 of 17)

The Medical Biller sends the Claim to the Wrong Managing Company

Insurance companies often delegate the management of some of their plans, or some services within plans (such as behavioral health) to other companies. Fail to realize this, and send a claim to anyone other that the managing company, and your claim could be denied.

Counseling Insurance Billing: Why Claims Are Denied (reason 10 of 17)

The Patient was Late to pay Their COBRA

COBRA is a government program where individuals can keep their health insurance after losing their job. However, those individuals need to pay 100 percent of the policy principle (a lot of money for someone out of work!). If a patient is behind on their COBRA payments, your claim will be denied.

Counseling Insurance Billing: Why Claims are Denied (reason 9 of 17)

The Patient Lost their Insurance Coverage

If a patient loses his or her insurance, your claim will be denied. This is not always evident, as some patients don’t know that they have lost their benefits, or may fail to inform you.

Counseling Insurance Billing: Why Claims are Denied (reason 8 of 17)

The Patient Changed Their Insurance Plan

If a patient changes his or her insurance plan, you will need to (a) be a provider networked in the new plan, and (b) get authorization for the new plan. Fail to do either of these actions prior to providing services, and your claim will be denied.

Mental Health Billing: Why Claims are Denied (reason 7 of 17)

The Authorization Timed Out

In addition to authorizations being for a specific number of sessions, they are also for a specific duration of time. Sometimes the timeframe is as short as 30 days. Provide services after the date of authorization expiration, and your claim will be denied.

Behavioral Health Billing: Why Claims are Denied (reason 6 of 17)

You Ran Out of Authorized Sessions

When authorization is granted, it is for a limited number of services / appointments. Lose track of how many appointments were approved, or how many you have provided, and you might find that you’ve provided sessions you won’t get paid for.

Behavioral Health Billing: Why Claims are Denied (Reason 5 of 17)

You Provided Two Services in One Day

With behavioral health, insurance companies have a strict “one service per day” policy. This means that even if a patient is authorized for 12 sessions of therapy, if you provide two sessions in one day, you won’t be paid for the second session. Clinicians who provide group therapy, psychological testing, or medication reviews beware—sometimes these services also fall under the one service per day policy.

Mental Health Billing: Why Claims are Denied (Reason 4 of 17)

The Patient Didn’t acquire a Referral from a Physician

Some insurance plans require not just authorization, but a referral from the patients primary care provider (PCP) before services can be rendered. Provide services before a patient referral is processed the insurance company, and the claim will be denied.

Mental Health Billing: Why Claims are Denied (Reason 3 of 17)

You Lacked pre-authorization

Preauthorization is a must for many insurance plans. Provide services without the proper authorization, and the claim will be rejected.

Medical Billing for Therapists: Why Claims are Denied (Reason 2 of 17))

The Insurance Company Lost the Claim, and the Claim Expired

Sometimes insurance companies misplace claims. If a misplaced claim doesn’t make it into the system before the deadline, the claim will be denied. Frustrated providers might find themselves talking to someone stating, “even though the error might have been on our end, there’s nothing we can do. The timeframe for filing has expired.”