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A secure prior authorization workflow stops administrative denials before they happen. We confirm benefits, submit clinical documentation, and initiate renewals before you deliver service.
Confusing eligibility verification with pre-service authorization drives uncollectible claim write-offs.
Confirms policy status and deductible balances. It does not approve clinical care.
Secures formal written authorization for specific CPT codes and unit counts based on medical necessity.
Every pre-certification request follows a disciplined operational pathway to secure timely determinations.
We verify if the patient’s benefits are managed directly or carved out to a third-party administrator.
We format your diagnostic assessment and treatment plan into the payer’s exact utilization portal format.
We transmit the initial request through the secure payer portal and capture formal tracking numbers.
Once issued, we log the authorization number and approved unit count directly into your billing system.
In recurring therapy, the greatest financial risk occurs when an approved block of sessions expires without clinical notice.
We decrement authorized units in real time as claims are filed. Our system alerts your practice and coordinates concurrent review submissions before care is interrupted.
Stepping down from partial hospitalization (PHP) to intensive outpatient (IOP) requires continuous authorization alignment to prevent claim rejections.
We submit your concurrent reviews 48 hours prior to transitioning a patient from partial hospitalization to IOP.
We secure authorizations for transitions to weekly individual or group psychotherapy by documenting clear clinical stabilization goals.
We manage your recurring medication authorizations alongside counseling sessions to ensure continuous treatment coverage.
Applying uniform authorization rules across different payers creates systematic rejections.
Commercial payers often allow initial outpatient sessions without prior auth but mandate pre-certification for psychological testing. State Medicaid plans frequently require prior authorization from session one.
Major medical plans routinely subcontract behavioral health to entities like Carelon or Optum. We prevent administrative rejections by submitting authorization requests directly to these carve-out portals.
Submitting authorization requests to general medical portals (Availity, NaviNet) instead of designated carve-out portals (Optum Provider Express, Carelon Portal) leads to automatic rejections while sessions continue unapproved.
We maintain clear boundaries between your clinical staff and our prior authorization team.
You submit patient demographic and insurance details prior to the initial appointment. We verify benefits and identify specific authorization requirements.
Your clinician completes the diagnostic evaluation. We format the documentation and submit the prior authorization request through the designated portal.
Upon receiving the payer determination, we log approved CPT codes and valid dates into your billing ledger.
When authorized units run low, we initiate the renewal workflow and request updated clinical notes to secure continuous coverage.
Therapy and behavioral practices often struggle between overburdened in-house staff and software-only auto-submission. See how a dedicated behavioral RCM pod changes the financial equation.
| Billing Capability & Standard | In-House Clinic Biller | Software Auto-Submit | MD Revenue GroupDedicated Behavioral Pod |
|---|---|---|---|
Specialized AAPC Behavioral Coders Certified experts who know psychotherapy timestamp rules, add-ons, and ASAM levels | Costly & Hard to Find ($65k+/yr) | None (No Human Review) | Included (Dedicated Behavioral Pod) |
Pre-Submission Timestamp Scrubbing Verifying notes match start/stop times before claims leave to stop 90837 downcoding | Inconsistent / Manual | Not Checked (Blind EDI) | 100% Pre-Claim Audit |
Automated Carve-Out Payer Rerouting Identifying Optum BH, Carelon, and Magellan before submitting to primary clearinghouse | High Error Rate | Routes to Primary (Rejection) | Automated Crosswalk Routing |
Aggressive Denial Appeals SLA Formal clinical narrative appeals for unworked denials within 48 business hours | Often Backlogged / Abandoned | Clinician Must Appeal | 48-Hour Systematic SLA |
Practice Pricing & Risk Alignment Compensation model aligned directly with actual collections and financial performance | Fixed Salary, Taxes & Overhead | Monthly Fee Regardless of Pay | Performance-Based (2.99%–8.5%) |
Long-Term Contract Commitment Flexibility to evaluate partnership value monthly without restrictive lock-ins | Severance & Re-hiring Friction | Annual Platform Lock-In | Month-to-Month (Earned Trust) |
We log approved authorization numbers, date spans, and session units directly into your billing ledger to ensure zero unbilled encounters.
We partner with practices that value documentation compliance and structured utilization management. Here is how we evaluate fit:
We do not hide behind anonymous offshore call centers or unverified software bots. MDRG provides direct access to credentialed revenue cycle managers and certified coding specialists.
Our coding and audit specialists maintain active credentials with the American Academy of Professional Coders (AAPC), ensuring precise CPT, ICD-10, and modifier application for behavioral healthcare encounters.
All data exchange, clearinghouse connections, and EHR interactions strictly adhere to HIPAA Omnibus standards, including 256-bit SSL encryption, restricted role-based access, and signed Business Associate Agreements (BAAs).
Founded by Faisal and Salwa in 2023 with over 13 years of combined revenue cycle leadership. Every practice has a named billing operations manager with direct phone and email escalation pathways.
Transparent month-end reporting on net collections, gross claims, denial categorization, and days in AR. We earn your partnership through monthly performance without restrictive multi-year lock-ins.
“Independent behavioral health clinicians should never have to sacrifice patient session time to battle commercial insurance clearinghouses. We treat your revenue cycle with the exact operational discipline you apply to patient care.”Faisal & Salwa — Founders, MD Revenue Group
Direct answers to common questions about behavioral health pre-certifications, concurrent reviews, peer-to-peer discussions, and carve-out plans.
No reputable billing company can guarantee authorization approval. Payer determinations are governed strictly by the patient’s specific plan certificate, clinical criteria, and documented medical necessity. MDRG ensures that requests are formatted accurately, submitted with complete documentation, and tracked persistently to prevent administrative rejections.
When an initial authorization request is denied, MDRG coordinates with your clinical team to evaluate options: requesting an expedited reconsideration, scheduling a peer-to-peer review with the payer’s medical director, or filing a formal Level 1 utilization appeal with supporting clinical addenda.
Payer turnaround times vary widely—from 48 to 72 hours for urgent outpatient requests to 14 business days for standard commercial pre-certifications. We recommend initiating authorization requests at least 5 to 7 business days prior to scheduled service dates.
Most commercial and Medicaid payers strictly prohibit retroactive prior authorizations, classifying unapproved past encounters as uncollectible provider write-offs. However, exceptions exist for emergency crisis evaluations or retroactive Medicaid eligibility determinations, which we pursue when permitted by contract.
We maintain an active tracking ledger linked to your EHR billing schedule. Every submitted claim decrements the authorized unit balance. When a client reaches 2 to 3 remaining units, our system alerts your practice to initiate the concurrent review renewal process.
Peer-to-peer reviews require a direct clinical discussion between the treating provider (or clinical director) and the payer’s medical director. MDRG coordinates the scheduling, gathers the clinical chart packet, and briefs your clinician on the specific medical necessity criteria in question.
Prior authorization tracking and concurrent review submissions are integrated into our core revenue cycle management service, billed as a performance-aligned percentage of net collections (typically 2.99% to 8.5%). See our pricing overview for detailed tier inclusions.
No. Our operational workflow review evaluates your authorization policies, intake timelines, and de-identified denial logs. We do not require patient names, member IDs, or psychotherapy clinical records for an operational consultation.
Discover where untracked authorization units, carve-out misrouting, and documentation lag are creating claim rejections. Zero patient-identifying data required.
Speak directly with an MDRG billing operations manager about your current pre-certification backlog, IOP/PHP utilization workflow, or carve-out friction. No sales pitch, zero claim data needed.
