Trends in Payor Disputes for Behavioral Health Providers

Healthcare attorneys Sandra Heller, Dan Silverboard and Tyler Gilbert published an article in the American Health Law Association's (AHLA) Health Law Connections journal analyzing growing scrutiny of the behavioral healthcare industry and highlighting trends in payer and government audits. As the authors explain, rapid industry growth, expanded use of telehealth and new mental health treatment modalities have called attention to this space, and payers ranging from commercial health plans to Medicaid managed care organizations to state enforcement authorities have responded in kind. The article distinguishes the types of reviews and audits behavioral healthcare providers may encounter in the pre-payment and post-payment phases as well as describes the involvement of payer Special Investigation Units (SIUs), which work to detect fraud, waste and abuse and can refer cases to the U.S. Department of Justice (DOJ) for potential prosecution. It then details what triggers audits – largely data analytics and identified outliers such as coding and billing irregularities, but also member complaints and False Claims Act (FCA) qui tam lawsuits. Sandra, Dan and Tyler call out the federal Anti-Kickback Statute (AKS) and Eliminating Kickbacks in Recovery Act (EKRA), along with their state counterparts, as particular areas of focus for SIU investigations and payer disputes. They additionally lay out strategies for anticipating and responding to audits, with steps including retaining healthcare regulatory and compliance counsel, understanding the dispute resolution provisions in payer contracts and conducting internal risk assessments on an ongoing basis.

READ: Trends in Payor Disputes for Behavioral Health Providers (AHLA membership required to view)

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