Behavioral health addiction treatment terminology refers to the specific language and terms used in the field of mental health and substance abuse. Synergy Concepts revenue cycle management is here for your behavioral health services.
Understanding behavioral health can sometimes feel like navigating through a maze of complex terminology. From psychotherapy to cognitive-behavioral therapy, the world of mental health can seem intimidating. Listed below are the definitions of many common behavioral health terminology. Synergy Concepts wants to help you navigate this complex billing space as easily as possible. If you have any questions, please contact us.
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The ACE Study
The Adverse Childhood Experiences Study was the largest scientific study ever conducted on the effects of negative childhood experiences on mental and emotional well-being later in life. The study examined the effect of childhood trauma on over seventeen thousand people, first in Southern California and later in Philadelphia. This is not a behavioral health term, per se, but anyone involved in the life of a child living with a behavioral health disorder should take the time to read this study.
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Addiction
A chronic disease characterized by compulsive drug or alcohol use despite negative consequences.
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Adverse Childhood Experiences (ACEs)
Traumatic events that occur in the life of a child increase their risk of developing long-term physical and/or behavioral health disorders.
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Allowed Amount
The amount an insurance company will pay to reimburse a healthcare service or procedure. The patient will typically pay the balance if there is any remainder.
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Anxiety
A mental health disorder characterized by excessive worry, fear, and apprehension.
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Appeal
The process by which a patient or provider attempts to persuade an insurance payer to pay for more (or, in certain cases, pay for any) of a medical claim. The appeal on a claim only occurs after a claim has either been denied or rejected (See “Rejected Claim” and “Denied Claim”).
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Applied to Deductible (ATD)
The amount of money a patient owes a healthcare provider that goes to paying their annual deductible (See “Deductible”). A patient’s deductible varies and depends on that patient’s insurance policy.
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Assignment of Benefits (AOB)
Insurance payments are paid directly to the healthcare provider for medical services administered to the patient. The assignment of benefits occurs after a claim has been successfully processed.
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Behavioral Health Challenge
What occurs when what a person feels, thinks, and does interferes with or interrupts their daily life? Behavioral Health Service: Refers to the various kinds of support a child receives for their behavioral health challenges.
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Behavioral Health Care Providers
This refers to the people whose job it is to help individuals facing behavioral health challenges. The most common providers are psychiatrists, psychologists, social workers, and various types of counselors and therapists.
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Behavioral Health Support Specialist
The general term for a person who comes to a school and offers behavioral health support to children in the classroom.
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Bipolar Disorder
A mental health condition characterized by extreme mood swings, including periods of mania and depression.
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Capitation
An arrangement between a healthcare provider and an insurance payer that pays the provider a fixed sum for every patient they take on. Capitated arrangements typically occur within HMOs (See “Health Maintenance Organization (HMO)”). HMOs, enlist patients to service providers, who are paid a certain amount based on the patient’s health risks, age, history, race, etc.
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Children’s Behavioral Specialist
A behavioral health professional who is specially trained to support children facing behavioral health challenges.
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Children’s Health Insurance Program (CHIP)
A federally funded health care program for children that provides low-cost health insurance to families who do not qualify for Medicaid. The range of coverage varies from state to state. In many states, CHIP also covers parents and pregnant women.
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Clean Claim
A claim received by an insurance payer that is free from errors and processed promptly. Clean claims are a huge boon to providers, as they reduce turnaround time for the reimbursement process and lower the need for time-consuming appeals processes. Many providers send their claims to third parties, like clearinghouses (See “Clearinghouse”), that specialize in creating clean claims.
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Clearinghouse
A third-party organization in the billing process, and separate from the healthcare provider and the insurance payer. Clearinghouses review, edit, and format claims before sending them to insurance payers. This process is sometimes called “scrubbing.”
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Centers for Medicare & Medicaid Services (CMS)
A federal agency that manages and oversees healthcare coverage through Medicare and Medicaid. CMS, if you remember from Section 2, also maintains HCPCS codes. CMS directly affects the healthcare of over 100 million Americans, and this number is growing every day. (See “Medicare” and “Medicaid”).
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CMS 1500
A paper form is used to submit medical claims to Medicare and Medicaid. Many commercial insurance payers also require providers to submit their claims using a CMS 1500, making this one of the most common and important tools in the medical billing process.
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COBRA Insurance
A federal program that grants a person recently terminated to retain health insurance with their former employer for 18 months, and up to three years if the former employee is disabled.
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Co-Insurance
A type of insurance arrangement between the payer and the patient that divides the payment for medical services by percentage. While this is sometimes used synonymously with a co-pay, the arrangements are different: While a co-pay is a fixed amount the patient owes, in a co-insurance, the patient owes a fixed percentage of the bill. These percentages are always listed with the payer’s percentage first (eg a 70-30 co-insurance).
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Community-Based Behavioral Health Services
Also known as “Wraparound Services.” These services are designed to help a child handle behavioral health challenges across the different areas of his or her life: at home, at school, and in the community.
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Community Support
In the behavioral health context, community support means groups that offer fellowship and peer assistance for a variety of behavioral health issues. The most well-known community support group – in this context – is Alcoholics Anonymous. Support is not only for people with alcohol or substance use disorders, however. Groups exist for people struggling with emotional and behavioral disorders, people dealing with grief and loss, and family members of people with substance use or other behavioral/emotional disorders.
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Complementary Therapy
Therapy is considered complementary when it meets two criteria: 1. It’s outside the mainstream, and 2. It’s used in conjunction with a traditional, conventional therapeutic approach. Complementary therapies include things like equine therapy, surf therapy, yoga, mindfulness, acupuncture, exercise, and meditation.
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Counselor
A licensed professional in the field of psychology. Counselors help patients change behaviors related to substance use, emotional, and/or behavioral disorders. A licensed counselor will hold a master’s degree (M.A.) in psychology or a related field.
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Depression
A mood disorder characterized by persistent feelings of sadness, hopelessness, and a lack of interest or pleasure in activities.
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Developmental Psychology
A subject that examines the stages of the mental and emotional growth of an individual, and how the physical and psychological aspects of an individual’s growth are related.
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Dual Diagnosis
The co-occurrence of a mental health disorder and substance abuse disorder in an individual.
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Explanation of Benefits (EOB)
A document attached to a processed claim explains to the provider and patient which services an insurance company will cover. EOBs may also explain what is wrong when a claim is denied.
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Electronic Remittance Advice (ERA)
A digital version of the EOB, this document describes how much of a claim the insurance company will pay and, in the case of a denied claim, explains why the claim was returned.
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Evaluation
The process a child who is experiencing behavioral health challenges goes through to determine the best ways to support that child. An evaluation must be performed by a certified professional, such as a medical doctor or a clinical psychologist.
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Family Therapy
A type of support or counseling that includes the family members – biological or otherwise – of the individual receiving treatment in the treatment process. Family sessions typically complement individual therapy.
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Fiscal Intermediary (FI)
A Medicare representative who processes Medicare claims.
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Group Therapy
A type of support session that involves a counselor (or psychiatrist, psychologist, or another behavioral health professional) working with more than one child at a time.
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Health Insurance Portability & Accountability Act (HIPAA)
A law passed in 1996 that has lasting effects on the healthcare industry today. Title I of the Act protects workers’ health insurance when they change or lose jobs. Title II of the Act established standards and best practices in electronic health care. Refer to Courses 3-8 and 3-9.
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Health Maintenance Organization (HMO)
A network of healthcare providers that offer coverage to patients for medical services exclusively within that network. We’ll cover this type of insurance more thoroughly in later videos.
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Independent Practice Association (IPA)
A professional organization of physicians or healthcare providers who have a contract with an HMO. HMOs contract IPAs to provide services to patients within the HMO’s network, but their practices do not have to be part of the HMO network.
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Inpatient Treatment
A type of treatment where the individual lives at the treatment location during treatment. This is often called residential treatment, or, more simply, rehab. However, rehab is an old term that mental health professionals no longer use. When they do use it, it’s typically informal or used while talking to people who aren’t mental health professionals.
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Integrated Treatment
A model of treatment developed to support individuals with co-occurring substance use and mental/emotional disorders. An integrated treatment model addresses alcohol/substance and emotional/behavioral disorders simultaneously, thereby increasing the chances of recovery for both.
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Intensive Outpatient Treatment
A level of support in which the individual spends part of a day – typically three hours – in treatment, but continues to live at home, go to school, or work. This type of treatment is for individuals who need more support than outpatient treatment, but less than inpatient/residential treatment.
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Managed Care Plan
A type of insurance plan that patients are only eligible to receive health care within the insurance company’s network. HMOs and IPAS (See “Health Maintenance Organization (HMO)” and “Independent Practice Association (IPA)”) are examples of the managed care system.
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Medicare
A government insurance program, founded in 1965, provides healthcare coverage for persons over 65 years old and people with disabilities. Medicare provides coverage to more than 50 million people in the United States today and is one of the common places you’ll send your medical claims to.
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Medicaid
Medicaid provides insurance coverage to low-income families and individuals. It is essentially an insurance program for those who cannot afford full insurance coverage. Medicaid is funded at state and federal levels, but each state has its version of Medicaid that must operate above the minimum requirements established by federal law.
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Medication Management
Medication management refers to the use of medication, such as antidepressants or anti-anxiety drugs, to treat mental health conditions. A qualified psychiatrist or nurse practitioner typically prescribes these medications and monitors their effectiveness and potential side effects. Medications can be a valuable tool in conjunction with therapy to help individuals find stability and relief from symptoms.
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Mental Health
The state of a person’s emotional, psychological, and social well-being.
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Mindfulness
Refers to a growing group of therapeutic practices loosely based on Eastern traditions such as yoga, tai chi, and meditation. Mindfulness, at its core, asks individuals to focus on the present moment, attune themselves to their immediate physical sensations and environment, and listen closely to their thoughts as they are now, not as they wish them to be in the future or as they were at some point in the past.
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Mobile Therapist
A counselor (or psychiatrist, psychologist, or other behavioral health professional) who travels wherever is necessary to give one-on-one support to a child or individual receiving community behavioral health (wraparound) services.
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Ongoing Care
Also known as aftercare. This phase of treatment occurs after residential, intensive outpatient, partial hospitalization, or general outpatient treatment. Ongoing care can include community support or regularly scheduled group or individual therapy.
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Outpatient Support
A level of support individuals receive in the office of behavioral health professionals. Outpatient service does not happen at home or in the school, but rather in a clinic, hospital, or other location.
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Partial Hospitalization
A level of support in which an individual spends a full day at the treatment location, but lives at home. Treatment typically occurs during the working/school week – Monday-Friday – and not on the weekends. This level of care is for individuals who need more support than outpatient or intensive outpatient treatment, but less than inpatient/residential treatment.
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Point of Service (POS) Plan
In this insurance plan, a patient in an HMO network can go to a physician outside of their network if they are referred there and pay a higher deductible. Think of this as a cross between an HMO and basic indemnity insurance (See “Health Maintenance Organization” and “Indemnity”).
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Positive Behavioral Intervention
A term used by schools to refer to a system of behavioral support put in place by a school or an entire school district. It involves students, parents, teachers, administrators, and anyone directly involved in the life of the child.
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Preferred Provider Organization (PPO)
A plan is similar to an HMO, except that the insurance company, rather than the HMO itself, decides who is in the acceptable provider network. This is a common, subscription-based type of managed care.
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Psychiatrist
A medical doctor (M.D.) who receives special training after medical school geared toward helping individuals facing mental and/or emotional challenges. A psychiatrist can prescribe medications to treat behavioral health challenges.
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Psychologist
A professional who studies human behavior and mental processes and provides therapy and counseling services.
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Psychotherapy
Psychotherapy is a term that frequently pops up when discussing behavioral health, but what does it mean? Well, put simply, it refers to a range of techniques used by mental health professionals to help individuals overcome emotional and psychological challenges. These techniques can include various forms of talk therapy, such as cognitive-behavioral therapy (CBT), dialectical behavior therapy (DBT), and psychodynamic therapy.
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Response to Instruction/Response to Intervention (RTI)
A general term that’s used in schools to describe how a child who is receiving behavioral health support is reacting to that support. It’s a way of asking and answering the question “How is the support working?”
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Schizophrenia
A chronic mental disorder characterized by abnormal social behavior, delusions, hallucinations, and disorganized thinking.
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Self-care
Activities and practices individuals engage in to maintain and improve their physical, mental, and emotional well-being.
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Sliding Scale
Individuals without insurance, or with insurance that does not cover behavioral health services, can ask for a sliding scale before they receive services from a professional. A sliding scale is an adjustment made by the provider that takes into account an individual’s specific income and/or insurance situation.
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SST, STS, SS
These are common acronyms that schools use to describe the teams they assemble to offer a child behavioral health support. A series of S’s and T’s typically stand for “Student Support Team” “Student Therapeutic Support” or “Student Services.” Terms are typically consistent within a state. However, these acronyms change from state to state.
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Stigma
Negative attitudes, beliefs, and stereotypes associated with mental health or substance abuse, lead to discrimination and social exclusion.
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Substance Abuse
The harmful or hazardous use of psychoactive substances, including drugs and alcohol.
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Therapists
Behavioral health care professionals who give individual counseling to children facing behavioral health challenges. Therapists typically hold a doctoral degree (Ph.D.) in psychology, counseling, or social work.
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Trauma
A psychological response to a distressing event, such as physical or sexual abuse, natural disasters, or witnessing violence.
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Trauma-Informed Care
An approach to counseling and behavioral health that takes into account the specific history of the individual facing challenges. This approach looks at what has happened in an individual’s past, and how it’s affecting an individual’s present life.
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Triple Option Plan (TOP)
Sometimes called a “cafeteria plan,” this plan provides individuals who sign up the option of choosing between an HMO, PPO, or POS coverage (See “Health Maintenance Organization (HMO),” “Preferred Provider Organization (PPO),” and “Point of Service (POS) Plan”).
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Tricare
Formerly known as CHAMPUS, this is a federal health insurance plan for active service members, retired service members, and their families.
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UB04
Similar in format to the CMS 1500 (See “CMS 1500”), this is another one of the most common claim forms.
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Utilization Limit
Medicare places a yearly limit on certain medical services. If a patient passes this threshold, known as the utilization limit, they may be ineligible for Medicare coverage for that procedure.
Behavioral Health Addiction Treatment Terminology is Important
Navigating the world of substance abuse treatment in behavioral health can be challenging, but understanding the terminology can make it a bit easier. Whether you’re considering treatment for yourself or just curious about the field, knowing the basics can be empowering. By unraveling the mysteries behind terms like psychotherapy, CBT, DBT, psychodynamic therapy, and medication management, you’ll be better equipped to make informed decisions about your mental well-being. Remember, knowledge is power, and the more you know, the more you can take control of your mental health journey.
Let’s work together to make your facility some synergy behavioral services. Contact us today.
