Reduced Eligibility Denials to Less Than 1% for a Mid-sized Behavioral Health Service Provider

The client

A mid-sized behavioral health and substance use disorder (SUD) service provider operating across all states in the United States.

Challenges Faced

Our client faced a significant issue with denials related to patient eligibility. With limited time to collect on denied claims, they needed a more effective strategy to enhance collections while alleviating patient dissatisfaction. Key issues included:

• High Eligibility Denials: Many claims were denied due to issues unrelated to the patient’s behavioral health coverage.
• Inefficient Collection Efforts: The billing team spent excessive time attempting to contact patients for updated insurance information, diverting focus from strategic initiatives.
• Unhappy Patients: Aggressive billing tactics to recover unpaid bills led to increased complaints and dissatisfaction among patients.

Plutus Health’s Plan of Action

Recognizing the need for immediate action, we implemented a comprehensive strategy to reduce recurring denials:

1. We built an in-house system with business and scrubbing rules to identify patient ID prefixes for specific payers and plans.
2. We created accurate behavioral health & TPA Carve Out Lists based on patient ID prefixes.
3. Our system now finds multiple layers of insurance instantly using limited patient data.

The new process allows:

• Accurate claim submission to the correct payer(s)
• Reduced claim rejections and Accounts Receivable days
• Billing patients with accurate balances after claim processing

Enhanced Collection Process

1. Insurance Layer Identification: Our advanced system enables instant identification of multiple insurance layers with minimal patient demographic data. By developing in-house claim scrubbing rules, we effectively matched patient ID prefixes to specific payers, ensuring accurate claim submissions.
2. Precision in Claims Submission: Claims are directed to the correct payer, drastically reducing rejection rates and improving overall cash flow. This targeted approach ensures that the client collects payments efficiently.
3. Clear and Accurate Patient Billing: Patients receive precise billing information post-claim adjudication, reducing confusion and complaints. This clarity enhances patient satisfaction and trust.

In Sum

Our solution helped the behavioral health service provider streamline their billing process, reduce eligibility denials, and improve patient satisfaction. This case study shows how targeted improvements in billing can lead to significant financial and operational benefits for healthcare providers.

To see the results download our case study