Blog

How Can Clinics Overcome Eligibility Verification Challenges in Mental Health Billing?

A mental health practice manager explained the difficulty of running eligibility checks. Their EHR system provided incomplete reports with no information on deductibles, co-pays, or co-insurance. Most results simply showed “limited” or “no information provided,” making it nearly impossible to give patients accurate cost estimates before appointments.

With payers directing providers to Availity, the situation became worse. Availity frequently marked all sessions as requiring prior authorization, even when benefits allowed them without it. Outages and missing data added to the frustration, forcing staff to spend hours on hold with insurance companies just to confirm coverage.

Inaccuracies with Availity and Payers

Several healthcare billing professionals described similar challenges. One explained that Availity often returned network errors for BCBSIL, showing “network not applicable” even when the provider was in-network. Others found that claims were being denied as duplicates due to errors in payer systems, including one case where claims were denied against a patient’s twin.

In behavioral health, some payer representatives gave incorrect benefit information. For example, one representative argued that family therapy was not covered, only to admit coverage once the correct CPT code was provided. This left providers frustrated and patients confused about their responsibilities.

EHR System Limitations

Practices using SimplePractice said that the system’s “coverage reports” did not provide the data needed for eligibility verification. When they contacted vendor support, the response was that the system was never designed to give full eligibility results. Some clinics considered switching to alternatives like AdvancedMD or eClinicalWorks, which offer more detailed verification, but those platforms often require additional customization and training to work properly.

Solutions Shared by Billing Experts

Billing specialists shared strategies that helped reduce denials and improve verification accuracy:

• Use the CF benefit type in Availity for outpatient mental health office visits.

• Create internal spreadsheets to track payer networks, alpha prefixes, and recurring issues.

• Where available, rely on payer-specific portals rather than clearinghouses for more accurate benefit details.

• Build redundancy processes, such as calling payers to confirm high-risk claims and maintaining documentation.

• Explore third-party automation tools that combine portal checks, payer calls, and data tracking into a single report.

One experienced biller noted that even with automation, manual oversight is still essential, especially in behavioral health where plan rules can differ significantly for telehealth, family therapy, and office visits.

New Approaches Clinics Are Testing

To cope with heavy administrative workloads, some clinics have begun testing external solutions. One provider mentioned working with a company that builds customized verification software, designed to integrate directly with payer portals and adapt to frequent changes. Another clinic used tools like runtalos.com, which generated full benefit breakdowns daily before each appointment, reducing billing surprises for patients.

The Impact on Care Delivery

For small clinics and mental health practices, inaccurate eligibility verification creates a major burden. Staff are often forced to spend long hours chasing information across multiple systems, which increases burnout and reduces time available for patient care. Patients, meanwhile, face unexpected bills when eligibility data turns out to be wrong, which can damage trust in both providers and the healthcare system.

What Did We Learn?

• Eligibility verification remains a major pain point for mental health and outpatient clinics.

• EHR systems like SimplePractice often fail to provide full or accurate benefit details.

• Payer portals such as Availity are widely used but frequently give incomplete or misleading data.

• Manual phone calls to payers are still necessary, creating heavy administrative burdens.

• Clinics are exploring solutions like direct payer portals, automation tools, and custom workflows.

• Patients are directly affected, often receiving inaccurate cost estimates and unexpected bills.

What People Are Asking ?

Q1. Why is insurance eligibility verification so difficult for mental health clinics?
Because payer portals like Availity often provide incomplete or inaccurate information.

Q2. What is the impact of faulty eligibility checks?
Clinics risk billing errors, patient dissatisfaction, and revenue loss.

Q3. Can EHR systems solve this issue?
Some EHRs like SimplePractice provide reports, but they are often limited and not reliable.

Q4. What can clinics do to manage eligibility better?
Use payer portals directly, build verification workflows, or adopt third-party automation tools.

Q5. How does this affect patients?
Patients may get unexpected bills if coverage details are missing or wrong.

Disclaimer

For informational purposes only; not applicable to specific situations.

For tailored support and professional services

Please contact Staffingly, Inc. at (800) 489-5877

Email: support@staffingly.com

About This Blog: This Blog is brought to you by Staffingly, Inc., a trusted name in healthcare outsourcing. The team of skilled healthcare specialists and content creators is dedicated to improving the quality and efficiency of healthcare services. The team passionate about sharing knowledge through insightful articles, blogs, and other educational resources.