Expansion from outpatient behavioral health into higher-acuity care models like IOPs and PHPs creates opportunities for revenue growth. But there’s a learning curve to billing for these programs, and if you don’t bill correctly, your bottom line will suffer.

Outpatient providers bill for individual services at every appointment, a model called professional billing. IOPs and PHPs use institutional billing—in other words, they bundle all services covered within the program into one bill. Professional and institutional billing use different forms and are sometimes subject to very different requirements from payers.

Learn how to make the switch, and discover strategies to guard against claims denials in institutional billing.

Professional vs. Institutional Billing

If you’ve billed insurance for outpatient services, you’re familiar with the CMS-1500 form. You use it to bill on a per-service basis using CPT codes. IOP/PHP billing is submitted on a UB-04 form, which allows for bundling multiple services into one claim, and uses different service and revenue codes.

A bundled claim would include all services a patient received in a given day, also called a “per diem” claim. IOP/PHP providers often bill in “units,” and the hours a patient spends in treatment determine the number of units billed.

Using both UB-04 and CMS-1500

In some cases, individual provider services within an IOP/PHP setting may not be covered under the bundled billing for the day, and will need to be billed separately on a CMS-1500 form. Program participation for the day is still billed institutionally, but services layered on top are billed professionally, the way outpatient therapy would be.

Some payers want you to bundle almost everything into the UB-04 institutional claim, while others expect, or at least allow, separate CMS-1500 claims. Checking with specific providers is important. Failure to bill correctly can lead to claims denial.

How Do I Know?

Not sure whether to use both forms or put everything on the UB-04? Here’s how to find out.

1. Check contracts with each payer. Ultimately, each payer decides what forms and structures are accepted.
2. Confirm state Medicaid rules if you expect Medicaid patients. These rules may differ between states.
3. Ask your facility’s compliance officer (if you’re joining an existing IOP/PHP).
4. If you are the program owner, decide how to structure your internal workflows. You have to bill according to your payer rules, but you get to decide how to structure your billing processes internally to support institutional and professional billing as needed.

This is where EHR systems built for behavioral health and IOP/PHP can help—by supporting both types of billing into one integrated workflow.

Considerations for Billing When Moving to IOP/PHP

If you’ve only experienced professional billing on CMS-1500 forms, there are some differences with institutional billing that you should consider.

1. Clearly document the medical necessity of an IOP or PHP program on every claim. Most payers want you to prove that a patient needs IOP or PHP care, as opposed to outpatient care. IOP and PHP represent a middle ground between outpatient and residential programs, and payers want to know it’s warranted.
2. Keep careful track of the hours you bill for, as many payers require that patients participate in a minimum number of hours per week in higher-acuity care models.
3. Detailed, individualized treatment plans are more important than ever. Payers are more likely to require detailed plans, individualized treatment, established goals, and movement toward those goals for IOP/PHP programs. The documentation you provide may need to be more detailed to demonstrate these things.
4. Prior authorization is required in many cases for an IOP or PHP program to be covered.
5. Periodic reevaluation and recertification by a physician is typically required on a regular basis for payers to continue coverage for a patient’s IOP/PHP treatment.

Find Tech that Supports the Transition

Expanding into IOP/PHP can feel overwhelming, especially if you don’t have extensive billing experience. One way to deal with the switch in billing practices is to find a technology platform that addresses many of the institutional billing pain points that practitioners encounter. Features such as:

• UB-04 form support
• Bundled claim capabilities
• Utilization review tracking
• Streamlined workflows
• Built specifically for behavioral health

Finding the right tech and learning the ropes of institutional billing can empower you to expand confidently while maintaining focus on patient care and program efficacy.