Why verifying patient mental health benefits accurately is critical to practice health

Many behavioral health practices recognize that verifying patients’ insurance information is a key factor in their success. But most operators are forced to under-resource this critical set of activities due to its inherent complexity and scale requirements.

The problems created by these broken benefit verification processes ripple through almost every function of a practice - from lower initial conversion and retention of new clients to impacted cash flow and overall practice health. 

The challenge, particularly in behavioral health, is in prevention at scale. It’s extremely time consuming for administrative teams to perform accurate benefit verification throughout the patient journey. And without a highly sophisticated technical solution, benefit structures in behavioral health are too opaque and complex to easily automate.

Why benefit verification is hard

There are two main reasons benefit verification is extremely time consuming for behavioral health practices: inaccurate data provided by patients and higher prevalence of complex benefit structures.

In reviewing a large data sample pulled from Nirvana’s behavioral health provider groups, it was found that an average of 18% of patients had incorrect information at intake, and even when patients provide the correct information it’s difficult for operators to parse complex benefit structures that vary across the hundreds of thousands of unique plans in the country.

Further, the complexity of benefit structures in behavioral health often requires the verifier to possess institutional knowledge and years of experience in order to succeed. Nirvana partners find that across their teams, a biller’s average accuray sits at around 75%. Even experienced billers who understand the opaque structures of mental health benefits, lack the out of the box tooling needed to act on insights like collecting new insurance cards, changing copays, and complex carve-outs.

The high costs related to incorrect benefit verification

1. Patient experience is closely tied to accurate cost estimation

Unsurprisingly, most patients seeking care won’t move forward without a clear understanding of how much it will cost. In mental & behavioral health, any additional barrier to care vastly increases the chance a patient will have a negative experience or forgo treatment altogether. An industry leading telehealth practice found that 30% of prospective patients drop out of the booking process once they are asked to input their insurance information online, further evidence that a lack of insurance literacy is a significant barrier to care.

The complexity of benefit structures in behavioral health makes getting a good cost estimate very difficult. When these errors occur, it adversely impacts patient care and retention due to delays and confusing, unexpected out-of-pocket expenses. In an analysis of top providers’ google reviews, over 20% of reviews referenced billing issues as points of contention. 

Strong operators monitor their cost estimate accuracy proactively and build systems to improve over time, but the problem only scales as volume increases, contract structures become more complex, and administrators turn over, costing providers critical institutional knowledge.

2. Incorrect patient demographics and ineligible policies lead to denials

The most common type of claim denial, representing roughly 20% of all denials in the Nirvana partner reviews, are due to data entry issues at intake. Errors as simple as using a preferred vs. legal name, spelling errors, or transposing two numbers in the member ID are consistently rejected by payers. Strong verification practices will compare the information that the patient gives the provider with what’s on file with the insurance, allowing issues to be corrected before a claim is filed.

Unfortunately, even a strong initial intake process doesn’t insulate practices - every month, 3-5% of patients’ policies terminate due to changes in employment, Medicaid eligibility, or other impacts. These transitions in coverage require an entire new intake process, but are often invisible to providers until after claims have been submitted. 

The strongest operators build systems that mitigate the issue with periodic checks, but lack of integrated workflows and overburdened admin teams often leave the practices reacting to the errors, rather than preventing them.

3. Verification failures are the root of RCM inefficiencies and collection problems

Whether a provider has incorrect information for a new patient at intake or outdated information for an existing patient, the result of submitting a claim is the same: preventable denials. 

As referenced above, an average of 18% of patients had incorrect information, which would lead to a claim denials. This incorrect data is the number one cause of claim denials for any behavioral health practice. Increased claim denials lead to RCM inefficiencies and collection problems. 

Today the healthcare industry average is 45-60 days Days Sales Outstanding (DSO)1 which is a burden for many practices. In stark contrast, Nirvana partner data shows provider networks that implement advanced verification systems in combination with pre-session collection dramatically reduce DSO, sometimes as low as to 8-10 days.

Why current eligibility solutions don’t solve the problem 

After understanding the importance of accurate benefit verification in boosting patient satisfaction,  reducing claim denials, and increasing revenue,  the question arises: what are providers doing about it? 

Today, many providers attempt to verify benefits through a combination of online portals, EHR solutions and a manual calling process. This generally takes place at intake, and often requires a 30-45 minute call with the patient’s insurance. 

This has three fundamental problems: 

The response time problem: Patients looking for a new provider are trying to make decisions quickly. With manual benefits verification, wait times to learn how much therapy will cost are often measured in days due to task backlogs and communication disconnects. This delay is an impactful barrier to care, and it also drives patients to seek alternative providers, reducing conversion.

The accuracy problem: Behavioral health benefits are complicated, and it’s difficult to train practice administrators on the nuances of thousands of distinct plans. Nirvana partner studies reviewed trained-biller accuracy in cost estimation, finding error rates between 6% to 34% depending on plan complexity and biller experience.

The shifting eligibility problem: Unfortunately, while manual benefit checks can be made for new patients, monitoring patients’ shifting eligibility over time is far too costly. If an average clinic of 10 providers were to attempt it with purely manual resources, they would require ~2 full time administrative staff doing nothing but benefit verification full-time. This leaves most practices relying on their patients to proactively report changes in insurance status, resulting in substantial ineligible policy denials and wasted biller time.

It is easy to see how a reliance on manual verification via phone calls can quickly overwhelm a benefit verification and billing team. Nirvana observes that providers utilizing this manual structure may recognize the problems it creates but often underestimate the downstream impacts of backlogged claim payments on their business. This underestimate, along with a status quo bias against implementing new systems, seems to be why many practices don’t seek alternative solutions.

1 Health Rev Partners, 2023

2 10 providers x 7 patients per day = 350 benefit verifications per week at an average of 12 minutes per verification = 70 hours per week.

Bridging the gap with technology: the way mental health verification should be

Regrettably, patients seeking mental health care have grown accustomed to a lengthy and cumbersome process for verification, appointment booking, and payment. But there is a better way.

Consider how financial services companies have embraced technology, enabling quick and frictionless payments for everyday items like a cup of coffee with credit cards and Apple Pay. Why can’t we make verifying insurance eligibility just as effortless for something as critical as mental health care? That is Nirvana’s mission. Achieving this level of harmonious integration in benefit verification, would significantly reduce barriers to patients receiving quality mental health care.

This is where creative applications of technology like AI and Machine Learning can help solve the downstream problems of manual patient verification. 

AI assisted workflows and flexible API solutions have proven to be the best way to get accurate eligibility and reliable cost estimates into the hands of providers and patients as quickly as possible and will be a paradigm shift for all. Nirvana’s AI assisted verification workflows prioritize urgent tasks and can eliminate unnecessary manual work entirely. 

Illustrated under the heading “How the Patient Journey Differs When Providers Use Nirvana”, one can see the stark contrast between a manual vs. AI assisted intake verification workflow.

The promise of benefit verification technology

At Nirvana, we recognize the opportunity to revolutionize benefit verification by leveraging AI and ML technologies. 

Our solution allows behavioral health teams to quickly and accurately verify patient information with 94% accuracy. Nirvana’s technology has enabled providers to instantly approve over 3 million sessions with full cost transparency every month for provider groups like Lifestance, Nystrom & Associates, and Geode Health, alongside EHR partners AdvancedMD and Valant, among others. Nirvana is a solution that benefits the provider network, their internal teams, the clinicians and the patient receiving care. 

With Nirvana, practices are able to reduce claim denials, increase revenue, and boost patient satisfaction by helping them receive the care they need with full cost transparency prior to treatment. 

By embracing innovative patient benefit verification technologies, practices overcome the hidden costs of inaccurate verification improving the overall efficiency, financial health, and patient satisfaction of their behavioral health practices. The impact of fast and accurate patient verification has massive impacts for all parts of behavioral health practices. 

We believe that by creating better systems for behavioral health practices, patients receive better care. As is our Motto: Better Systems, Better Care. 

If you are looking to improve your operational efficiencies, explore Nirvana’s Intake, Continuous Coverage Monitoring and Custom Solutions here.

The author of this piece, Akshay Venkitasubramanian, is the Co-Founder & CEO of Nirvana