PROTECT YOUR REVENUE

The R.I.S.E. Series

A 4-Part Series for Behavioral Health Facility Owners | April–July 2026

If you’ve noticed things getting weird out there — more denials, more record requests, more pushback — you’re not imagining it.

Payors are under regulatory pressure like never before. In California, DMHC penalized Anthem with a $15 million fine and DHCS issued monetary sanctions. CMS restructured the distinct IOP benefit nationally in 2024. Every payor in every state is recalibrating — and the scrutiny is rolling downhill fast.

Your TIN. Your NPI. Your revenue. Your risk.

The Full R.I.S.E. Series

A 4-month deep dive into compliance, exposure, and your rights as a facility owner.

R — Regulatory Notice I APRIL

Your payors are on notice. Audits are accelerating. California is where the hammer is falling first — but this is national. Details below.

I — Impact & Exposure I MAY

Your financial and legal exposure is real. Full recoupment, interest, penalties, network exclusion, and potential fraud referrals. Six to seven figures. Details to come.

S — Standards in Coding I JUNE

If your codes aren’t compliant, you’re the one holding the bag — not your billing company. Their name isn’t on the claim. Yours is. Details to come.

E — Enforcement & Rights I JULY

The only defense is knowing your regulatory rights — how to challenge denials, demand transparency, and hold your billing partner accountable. Details to come.

Join the ROC on Tuesday, April 14th, as Erin Burke, CEO & Founder of Hansei Solutions, sits down with Jenna Joneikis, CCS, CRCR, CSPR — Hansei’s Senior Revenue Integrity Analyst and AHIMA-certified coder — for an unfiltered look at what’s happening in behavioral health billing right now.

Jenna was the analyst who identified the HCPCS coding gaps currently putting California facilities at risk of full recoupment. She’s going to walk through what she found, why it matters, and what the patterns tell us about where enforcement is headed nationally.

WHAT WE’LL COVER

• The regulatory landscape: what’s driving the surge in audits, denials, and medical record requests

• Why California is the flashpoint — and why every other state is 6 to 12 months behind

• The specific coding patterns Jenna flagged in the data — and what’s at risk

• How to tell if your RCM partner is billing defensibly — or putting your facility at risk

• What every rehab owner should be paying attention to right now

45 Minutes. Bring Your Questions.

Jenna Joneikis

Senior Revenue Integrity Analyst

Hansei Solutions

Erin Burke

CEO & Founder

Hansei Solutions

March 2026: Deductible Season & Marketplace Changes

Thank you to everyone who joined us for this month’s ROC!

This month’s discussion, led by Erin Burke and Emily Macri from Hansei Solutions, focused on how the 2026 deductible season and ACA marketplace changes are increasing patient financial responsibility and reshaping revenue cycles nationwide.

Deductible Season and Marketplace Shifts

This year’s deductible season is unfolding differently than in prior years. Changes in ACA marketplace policies — including the expiration of enhanced subsidies — are pushing many patients toward plans with higher deductibles and larger out-of-pocket maximums. As a result, providers are seeing greater patient financial responsibility much earlier in the year.

These shifts are disrupting traditional deductible-season revenue patterns and creating new challenges for forecasting cash flow and collections.

The team also reviewed Hansei’s seasonality index model across our partner network. Historically, revenue patterns follow a predictable deductible reset cycle, but marketplace plan changes accelerated deductible pressure earlier in the year. Many partners experienced financial impact faster and more intensely in January and February, particularly in markets such as Texas, though the trend is being seen nationally.

Because many patients are selecting lower-premium plans with higher cost-sharing requirements, providers — especially in behavioral health and substance use treatment settings — are facing increasing challenges collecting patient balances.

Addressing Patient Financial Responsibility

As patient financial responsibility increases, strong front-end financial processes are becoming critical to maintaining stable cash flow.

Accurate patient financial estimates and early financial counseling can significantly improve collections and reduce downstream revenue cycle pressure.

Organizations are increasingly using tools such as:

• Financial responsibility calculators

• Structured payment plans

• Third-party financing options

Understanding payer mix and marketplace plan structures is also becoming increasingly important for revenue forecasting and operational planning.

ACA Policy and Marketplace Challenges

Several structural changes in ACA marketplace plans are contributing to these pressures.

What Changed

• Federal OOP maximum increased to $10,600 individual / $21,200 family

• Bronze and some Silver deductibles moved closer to OOP max

• Coinsurance in some markets increased (up to 50%)

• Greater early-year member liability

Provider Impact

• Slower payer remittance in Q1

• Higher patient AR balances

• Increased collectability risk (especially BH/SUD)

• Greater working capital pressure

Key Takeaways

• Review exchange exposure by state and metal tier mix

• Update eligibility verification and benefit breakdown workflows

• Strengthen upfront collection and payment plan protocols

• Adjust Q1 cash forecasting assumptions

• Reassess bad debt reserve assumptions for exchange-heavy markets

BCBSTX Structural Changes (2025 → 2026)

• Individual OOP max: $9,200 → $10,600

• Bronze deductibles: Up to ~$10,600

• INN coinsurance: 30–40% → Up to 50%

Texas risk is amplified due to:

• Large ACA enrollment

• High Bronze penetration

• Significant BCBSTX exchange market share

Financial Impact Outlook

Short-Term (Q1 2026):

• 10–25% decline in payer cash receipts for exchange-heavy facilities

• Increased patient AR

• DSO expansion

• Working capital utilization increases

Medium-Term:

• Partial normalization as accumulators fill

• Elevated bad debt risk

• Potential margin compression if cost-share is not collected

Key Takeaways & Action Items

• Model Q1 liquidity compression scenarios

• Evaluate the exchange payer mix concentration

• Review payment plan performance and default rates

• Revisit bad debt assumptions and covenant sensitivity

• Assess borrowing base exposure if AR shifts toward patient balances

Medical Record Requests and Coding Changes

Another topic raised during the discussion was the increase in medical record requests and payer audits, particularly from large insurers. Preparing documentation for these requests places additional operational burden on providers and reinforces the need for consistent and comprehensive clinical documentation.

Coding policy updates are also creating new challenges. Recent ASAM-related coding changes tied to a major payer are affecting how claims are adjudicated, and incorrect revenue coding has led to increased claim denials in some cases. Maintaining accurate revenue codes and compliant billing practices is increasingly critical.

Payment Disputes and Payer Reviews

Participants also discussed the growing number of post-payment reviews and special investigations from major payers, including retroactive recoupment activity.

These reviews can require extensive documentation and may challenge claims that were previously paid. Organizations are encouraged to carefully review payer requests, document agreements clearly, and push back when necessary on post-payment audits that appear inconsistent with prior approvals.

Additional Q1 OON Pricing & Routing Trends Impacting Revenue

Aetna (OON)

A recurring routing pattern continues to appear with Aetna out-of-network claims.

Aetna claims typically do not route to GCS for pricing until the deductible is satisfied, a pattern that has remained consistent over the past several years.

While deductible thresholds are still being met:

• Claims are adjudicated without GCS pricing

• Allowed amounts are lower

• Deductible accumulation progresses more slowly

Once the deductible is satisfied, claims begin routing to GCS, and reimbursement patterns shift accordingly.

Anthem / MultiPlan

Beginning with DOS 2/1/26, we are observing:

• Reduced allowed amounts for DTX/RTC

• Broader reductions in allowed amounts across Anthem plans

This shift does not appear limited to TPA-priced claims, suggesting a potential payer-level pricing adjustment rather than a MultiPlan-only change.

Cigna / Data iSight

Recent trends show mixed but noteworthy changes:

• Negotiated rates are lower than historical benchmarks

• More claims are now being marked negotiable (previously many responses were “non-negotiable”)

Typical incremental negotiation movement:

• IOP: ~+$20 per diem

• PHP: ~+$50 per diem

• DTX/RTC: ~$200–$300 per diem

The result is more negotiation opportunities, though per-claim upside remains modest.

Strategic Considerations for Q1

As organizations continue navigating deductible season and marketplace changes, several strategic considerations remain top of mind.

Providers should expect early-year cash flow compression tied to Aetna deductible routing, while closely monitoring Anthem trends for potential systemic pricing changes.

At the same time, organizations are encouraged to lean into Cigna negotiation workflows. While the per-claim lift may be incremental, consistent engagement can help mitigate revenue loss over time.

Remaining proactive with payer monitoring, documentation, and negotiation strategies will be key to maintaining financial stability throughout the year.

We’ll see you next month! Stay tuned for details.

Tuesday, April 14th

11:00 am - 12:00 pm PST I On Zoom

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Teaser - March 10th: 2026 ACA Marketplace Changes, BCBSTX Impact & Q1 Pricing Trends

Join Erin Burke, Founder & CEO, and Emily Macri, Client Executive at Hansei Solutions, for a focused discussion on 2026 ACA Marketplace changes, Texas cost-share redesigns, and emerging Q1 payer pricing and routing trends — and what they mean for behavioral health and SUD providers.

With higher deductibles, increased out-of-pocket maximums, and coinsurance reaching up to 50% in some markets, providers should expect greater early-year patient responsibility and cash flow pressure.

Tuesday, March 10th

11:00 am - 12:00 pm PST I On Zoom

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We’ll cover:

• 2026 National ACA changes

  • OOP maximum increases

  • Deductibles moving closer to OOP max

  • Increased coinsurance and early-year liability
    

• Texas BCBSTX Marketplace redesign

  • Higher deductibles and OOP limits

  • INN coinsurance up to 50%

  • Liquidity and margin impact for SUD facilities
    

• Q1 revenue & pricing trends

  • Aetna OON deductible routing patterns

  • Anthem/MultiPlan allowed amount shifts

  • Cigna negotiation trends and per diem movement

If you operate in exchange-heavy markets, this session will help you prepare for cash flow pressure and adjust ahead of these changes. We’ll see you soon!

Tuesday, March 10th

11:00 am - 12:00 pm PST I On Zoom

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February 2026: Smart UR Strategies to Stay Compliant Without Compromising Care or Revenue

Utilization Review (UR) is evolving fast. In 2026, providers are navigating a landscape shaped by regulatory shifts, payer policy changes, and growing pressure to reduce administrative burden—all while protecting access to care and financial sustainability.

Thanks to insights from Lauren Jensen, Director of Utilization Review at Hansei, we explored how smarter UR workflows can help organizations stay compliant, reduce denials, and safeguard both care delivery and cash flow.

If you missed it, you can view the recording here:

https://hanseisolutions.zoom.us/rec/share/3dmTNibJiiXTedFXeO7RqDOwz1dIgvJ5XV59iGTlah2uQgluhKbu8R_QUL-UFpKO.FetkA40eJzt-4Oew

Passcode: 1xpD*P=1

Data-Driven UR in a Changing Landscape

Hansei’s scale offers a rare view into the realities of modern UR. With analysis spanning 2 million verifications of benefits (VOBs) and millions of claims, we’ve found clear patterns emerging.

That said, UR processes must align tightly with national clinical standards and payer compliance requirements. When workflows drift from these benchmarks, denial rates rise, and teams are left reacting instead of planning.

At the same time, the administrative load on clinicians and UR teams continues to grow. We highlighted how agentic AI can play a role in streamlining repetitive tasks, allowing teams to focus on higher-value clinical and coordination work rather than paperwork.

The Operational Realities & Challenges of UR

UR challenges are rarely theoretical—they show up in day-to-day operations.

Lauren noted that many teams struggle with multiple care managers assigned to the same client, which can fragment communication and create inconsistencies in documentation. Without a centralized approach, this complexity increases denial risk and slows down authorizations.

Strong clinical documentation remains the backbone of effective UR. Clear, consistent notes that articulate medical necessity are essential—not only for approvals, but also for successful appeals when denials occur. Clinicians who understand how UR works, and why certain details matter, are far better positioned to protect both patient care and reimbursement.

Why UR Coordinators Belong on the Treatment Team

One of the strongest themes from the discussion was the value of embedding UR coordinators directly into treatment teams.

When UR professionals are seen as partners rather than gatekeepers, communication improves. Trust builds. Clinicians feel supported instead of scrutinized. This collaboration leads to cleaner documentation, faster authorizations, and fewer preventable denials.

UR coordinators also serve as guides—helping clinicians navigate shifting payer rules, interpret requirements, and adjust documentation in real time. Their role is not just administrative; it’s strategic.

Flexibility Is No Longer Optional

Payer requirements continue to vary widely, and rigid UR workflows simply don’t hold up. Teams must remain flexible, adapting processes based on payer mix and levels of care.

UR allocation per person reflects this reality. In some settings, coordinators may manage around 15 reviews per day; in others, especially with more complex payers or higher acuity levels, 6 per day is more realistic. Capacity planning has to account for complexity—not just volume.

2026 UR Shifts: Reducing Barriers to Care

Looking ahead, 2026 is bringing meaningful shifts in utilization review, particularly in behavioral health.

• Some states and payers are limiting or waiving UR requirements for the initial hours or days of care

• Criteria are increasingly evidence-based and parity-aligned

• Opaque, payer-specific rules are being phased out in favor of standardized approaches

Documentation Matters More Than Ever

As UR becomes more standardized, documentation is under greater scrutiny.

• Reviews rely heavily on nationally recognized clinical standards

• Medical necessity must be clear, consistent, and well supported

• Strong documentation not only prevents denials—it strengthens appeals when they occur

In short: good documentation is no longer just good practice; it’s a financial safeguard.

Smart Workflows Protect Care and Cash Flow

The most resilient organizations are investing in smart UR workflows that balance compliance with efficiency:

• Automating authorizations to reduce administrative burden

• Aligning UR processes to clinical standards to improve approval rates

• Tracking denials in real time to prevent treatment disruptions and reimbursement delays

Teaser - February 10th: Let’s Talk 2026 Utilization Review Changes

Smart UR strategies to stay compliant without compromising care or revenue

Utilization review is shifting toward fewer access barriers, greater reliance on evidence-based clinical standards, and increased scrutiny of documentation. Facilities that align UR processes with national standards and build smarter workflows can stay compliant, reduce denials, and protect both care delivery and cash flow.

Join Patrick Dunn, Chief Strategy Officer, and Lauren Jensen, Director of Utilization Review at Hansei Solutions, for an open discussion as we dive into 2026 Utilization Review changes—what’s coming, what it means for your facility, and how to stay compliant without slowing down care or cash flow.

January 2026: The 2026 Payor Outlook

Insights, Trends, and Strategy

Thank you to everyone who joined us for our first ROC Masterminds discussion of 2026. This session, led by Hansei Solutions, focused on reflecting on the changes and challenges providers faced with payors in 2025—and what those trends suggest for the year ahead.

If you missed the session, you can view the full recording here:

View Recording: https://hanseisolutions.zoom.us/rec/share/k1-T1raQT5RtHl6-HUjvHDTweeduehFYa69E-Jj0v7LeDOA4-rSFDybNurModIn8.nC9OPPYC73Z_Pli-

Passcode: TJ+*5aAw

Below is a recap of the key takeaways and strategic insights discussed.

Looking Back: Key Payor Trends from 2025

Across multiple states, providers noted that unusually favorable payor behavior often preceded later challenges. This sentiment was echoed nationally, particularly in conversations around fee schedules and claim handling. Hansei also reported a noticeable uptick in audits throughout 2025, adding to the already heavy administrative burden providers faced—an issue expected to remain a key discussion point in 2026.

Claim Denials and Administrative Disruptions

• Colorado providers reported widespread claim denials where replacement claims were deleted, new information was inserted, and original claim data was removed—even when referencing the original claim number. This may be tied to HCPCS/HIPPS coding issues, though clarity remains limited.

• Similar concerns were raised in Texas and Virginia, highlighting the lack of consistency across states.

Payor-Specific Insights

While many challenges in 2025 were felt across the industry, certain payors stood out due to recurring patterns, enforcement shifts, and increased administrative strain. Below is a closer look at the payor-specific trends discussed, highlighting where providers experienced the greatest disruption and what may carry into 2026.

Ambetter

• Providers across the Southeast—including SC, NC, TN, TX, AR, MS, FL, KY, and GA—reported significant challenges.

• 2025 proved especially difficult due to:

  • Historically confusing contracts

  • Changes in rates and service language

  • Inconsistent enforcement of policies

• While Ambetter appears to be moving toward consolidation and standardization, execution remains inconsistent from state to state.

• Provider manuals are being enforced more strictly, yet authorization backlogs, inconsistencies, and turnaround delays—especially for lower levels of care—persist.

Aetna

• Audit flags emerged in 2025, a notable shift from prior years, as many providers had not encountered Aetna audits before 2024/2025.

• Audits are impacting both in-network and out-of-network providers.

• There is concern that actions by a small number of “bad actors,” particularly in California but also nationwide, may be driving these broader enforcement trends.

• The result: a significant administrative burden for compliant providers.

Cigna

• Retrospective reviews were a major pain point, with attendees noting that no one present had successfully passed one to date.

• There is growing concern that behavioral health providers are being disproportionately targeted.

• Hansei encouraged providers to share insights and data to help identify patterns and support potential parity complaints, as these practices may represent systemic exploitation of providers.

Looking Ahead: What 2026 Is Likely to Bring

Affordable Care Act (ACA) Implications

• ACA plans are trending toward narrower networks across all states.

• As premium payment structures evolve, providers should prepare for increased scrutiny and tighter contracting.

Case Rates and Contracting Strategy

• Payors are increasingly interested in case rates, but they need clarity from providers.

• The takeaway: you must clearly define and communicate what you do.

• Communication cannot be overstated—it is not possible to overcommunicate.

Defining Quality and Outcomes

Payors are looking to providers to lead the conversation on quality:

• Show your outcomes.

• Define what success looks like for your patient population.

• Recognize that adult and adolescent outcomes differ, and your benchmarks should reflect that.

• Consider broader quality-of-life indicators:

  • Living stability

  • Employment

  • Medical engagement

  • Reduced ER visits

  • Overall patient well-being and satisfaction

Providers know their patients best—and payors have acknowledged that they rely on providers to build, study, and define their own outcome measures.

Full Continuum of Care Matters

• Outcomes should reflect pre-treatment and post-treatment trajectories, not just a single episode of care.

• Establish internal benchmarks and track progress over time.

• Research partners, such as Vista Research Group, were mentioned as valuable resources in this area.

Staying Connected and Moving Forward

ROC’s objective remains the same: we are a team. If you need support, insight, or want to share updates on how payors are impacting your organization, please reach out: ROC@hanseisolutions.com.

And don’t forget—join us for the upcoming ATAC Event in Long Beach, CA, on Tuesday, January 20th. Learn more: https://events.atac.org/

Finally, stay tuned for more updates soon. February will bring early indicators of how these changes are materializing, so stay tuned. We’ll see you next month!

Hello ROC Members,

It has come to our attention that our monthly recurring Zoom calendar invitation may not display correctly on some calendars—particularly in Outlook. We apologize for the inconvenience this has caused.

We are currently working with Zoom to have everyone who is registered for the ROC meeting series re-receive an updated calendar invitation via email. While that process is still in progress, we’d like to share a few alternative solutions you can use in the meantime to ensure you don’t miss any meetings.

Meeting Access

You may continue to use our standard Zoom meeting information below:

Zoom Link:
https://us02web.zoom.us/j/86898814429?pwd=OWVvSC9qUVZiZ1RDQ0FESDZOMWpDZz09

Meeting ID: 868 9881 4429
Passcode: 587980

Our standard registration link is also still active for new users wanting to register:
https://hanseisolutions.zoom.us/meeting/register/tZIlfuGgrz8uGN2GuS6O1L4oeQE5PBrEFB7y#/registration

Microsoft Outlook Users: How to Fix the Calendar Issue

You have two options to ensure the meetings appear correctly on your calendar.

Option A: Manually Add the Meeting Series

You may manually add the recurring meeting to your calendar using this info:

https://us02web.zoom.us/j/86898814429?pwd=OWVvSC9qUVZiZ1RDQ0FESDZOMWpDZz09

Meeting ID: 868 9881 4429

Passcode: 587980

Option B: Upload the .ics Calendar File

1. Download the file here and save it to your desktop.

2. Open Outlook and click the Calendar icon.

3. Select Add Calendar from the left sidebar.

4. Click Upload from File.

5. Choose Browse, select the saved .ics file, and click Import.

6. Once imported, the calendar series should appear for the second Tuesday of every month in 2026.

2026 Meeting Dates & Times

All times are listed in Central Standard Time (CST):

• January 13, 2026 – 1:00 PM CST

• February 10, 2026 – 1:00 PM CST

• March 10, 2026 – 1:00 PM CST

• April 14, 2026 – 1:00 PM CST

• May 12, 2026 – 1:00 PM CST

• June 9, 2026 – 1:00 PM CST

• July 14, 2026 – 1:00 PM CST

• August 11, 2026 – 1:00 PM CST

• September 8, 2026 – 1:00 PM CST

• October 13, 2026 – 1:00 PM CST

• November 10, 2026 – 1:00 PM CST

• December 8, 2026 – 1:00 PM CST

If you have any questions or continue to experience issues, please don’t hesitate to reach out to us at marketing@hanseisolutions.com.

Thank you for your patience, and we look forward to seeing you at our upcoming meetings!

Insights, Trends, and Strategy for ROC

The 2026 Payor Outlook

As we enter 2026, one thing is clear: payor dynamics are shifting faster than ever, and rehab owners and operators are being asked to adapt in real time—often with limited clarity or warning.

That’s why we’re kicking off the 2026 ROC Masterminds with a focused conversation on what actually changed in 2025—such as U.S. Department of Veterans Affairs (VA) contracts and Ambetter Health plan developments—and, more importantly, what Hansei and ROC see coming next so you can plan with confidence instead of reacting under pressure.

What We’ll Cover

2025 in Review

• U.S. Department of Veterans Affairs (VA) Plans

• Ambetter Health Plans
  

Looking Ahead to 2026

• Affordable Care Act (ACA) Plan Changes

• Blue Shield of California and Magellan Health Updates

The decisions you make in early 2026—around documentation, clinical alignment, contracts, and payor strategy—will directly shape your margins and scalability for the year ahead. This session is designed to help you connect the dots between policy, payors, and day-to-day operations, with insight from Hansei and ROC grounded in what we’re seeing across the field.

We’ll see you soon!

Trends In Payor Disputes and the Interplay of Regulatory and Compliance

Thank you to everyone who joined us for our November ROC discussion with Sandy Heller and Dan Silverboard from Holland & Knight Law. The conversation focused on how payor disputes are evolving—especially for behavioral health and substance use disorder providers—and what organizations can do to strengthen their position through compliance, documentation, and smarter network contracting.

Below is a recap of the key takeaways.

The New Reality of Payor Disputes and Audits

Sandy opened by framing the current landscape: providers are facing a growing mix of underpayments, non-payments, prepayment reviews (PPRs), post-payment audits, and SIU activity. Behavioral health providers, particularly in SUD treatment, are experiencing a significant uptick in:

• Prepayment reviews, often coupled with

• Extrapolation and offsetting, where payors use a sample of claims to justify recoupments across a broader universe.

The core message: disputes are no longer just isolated billing issues. They sit at the intersection of regulatory enforcement, payor-driven analytics, and contractual rights, and providers need to respond strategically—not reactively.

Understanding Audit Types & Why Definitions Matter

Not all audits are created equal, and it’s emphasized that it’s important to understand what you’re facing:

• Routine audits may be framed as standard reviews or quality checks.
  Data-driven and SIU audits are often based on analytics and outlier detection, and can carry a higher risk.

Knowing which type of audit you’re dealing with shapes your strategy, including when to involve counsel and how aggressively to push back. Providers should also monitor audit activity over time to spot patterns that might signal broader payor initiatives.

“Document Gotchas” and the Power of Record-Keeping

One recurring theme: documentation can make or break your position.

The H&K team highlighted common “document gotchas,” where minor errors in documentation can lead payors to invalidate entire records or deny claims, for example:

• Incomplete or inconsistent treatment plans

• Misaligned notes and billing codes

• Discrepancies between what’s documented and what’s billed

In addition to clinical records, operational documentation matters:

• Track what you submit to payors and when.

• Keep copies of all records sent.

• Calendar audit deadlines and expected outcomes.

• Save correspondence and explanations of benefits (EOBs), especially when reason codes are unclear or indecipherable.

This paper trail is critical when you need to challenge misrepresentation claims or appeal adverse findings.

Compliance at the Center: Statutes, SIUs & Risk Areas

Dan walked through the federal and state laws that payor SIUs and regulators routinely look at, including:

• Anti-Kickback Statute (AKS)

• Eliminating Kickbacks in Recovery Act (EKRA)

• False Claims Act (FCA)

• Beneficiary inducement rules, including restrictions on routinely waiving coinsurance and deductibles

For behavioral health providers in particular, he stressed:

• Billing and coding accuracy

• Appropriate treatment plan documentation

• Compliance with licensure and supervision requirements

• Group size and staffing rules

• Relationships with referral sources and third parties, to avoid any appearance of improper remuneration or inducements

How AI and Analytics Are Shaping Audit Risk

Dan also emphasized how payors are increasingly relying on analytics and AI tools to inform audit targeting and payment decisions. These systems flag:

• Outlier billing patterns

• High-cost services or unusually high utilization

• Coding combinations that don’t fit expected norms

He noted examples, such as UnitedHealthcare’s use of Evercore’s Heavy Core product, as part of a broader trend toward automated, data-driven oversight.

For providers, this means:

• You may be flagged before you even know there’s a concern.

• Your internal data and compliance monitoring need to keep pace.

• Understanding your own outlier status—before the payor tells you—is key.

Network Contracting: The Hidden Driver of Audit Leverage

Beyond pure regulatory risk, network contracts can quietly shape the playing field for audits and disputes. Sandy encouraged providers to:

• Review contracts for provisions that expand payor audit rights, limit appeal options, or enable broad recoupment.

• Identify opportunities to negotiate more balanced terms, especially around audit scope, timeframes, documentation standards, and offsets.

• Understand what you’ve already agreed to before responding to an audit or dispute.

In many cases, providers discover contractual language that gives payors more leverage than they realized, simply because it wasn’t scrutinized during the initial contracting process.

Strategies for Responding to Audits & Disputes

1. Respond strategically, not emotionally
   Treat each audit as a legal and business event. Involve trusted counsel early, especially where extrapolation, large offsets, or SIU involvement are in play.

2. Control your submission process

   • Document exactly what you send and when.

   • Use organized, complete packages.

   • Keep proof of transmission and receipt.

3. Track outcomes and deadlines

   • Calendar appeal windows and expected decision dates.

   • Follow up when payors miss their own timelines.

4. Use provider education meetings
   When available, request provider education sessions to clarify expectations, dispute mischaracterizations, and establish a record of good-faith engagement.

5. Be willing to escalate
   Not every dispute can—or should—be resolved at the claims level. Escalation options may include:

   • Internal payor escalation channels

   • Involvement of counsel

   • Regulatory complaints

   • Litigation in appropriate cases

Looking Beyond the Payors: Regulators, Parity & Coalitions

A major theme of the conversation was the importance of looking outside the payor’s four walls:

• Engage state insurance regulators, especially around:

  • Mental health and substance use disorder parity issues

  • Recurring problematic practices (e.g., patterns of denials or burdensome audits

• Consider forming provider coalitions
  Systemic issues rarely affect just one provider. Coalitions can:

  • Share data and trends

  • Amplify concerns with regulators and legislators

  • Coordinate strategies for dealing with specific payors or practices

Collective action can shift the conversation from “this provider’s problem” to a broader policy issue that regulators are more likely to address.

Key Takeaways

• Invest in a robust, tailored compliance program, especially in behavioral health and substance use disorder care.

• Tighten documentation and record-keeping, both clinical and operational.

• Understand and, where possible, improve your network contract terms related to audits and recoupments.

• Prepare for AI-driven, analytics-based audits by monitoring your own data and outliers.

• Engage with regulators and build coalitions to address systemic payor practices, particularly those related to parity and access to care.

As payor disputes and audits grow more complex, the most successful providers will be those who treat compliance, contracting, and regulatory engagement as integrated, strategic functions—not isolated, reactive tasks.

We’ll see you next month!

Sandra L. Heller

Partner

Sandra.Heller@hklaw.com

Sandra Heller is a South Florida attorney with a national practice focused on healthcare reimbursement disputes between providers and payors. She represents behavioral health facilities, hospitals, and health systems in resolving denied or delayed claims, maintaining payor relationships, and managing audits and investigations. A skilled litigator, she has extensive experience with ERISA cases, insurance fraud, and recovery actions in both state and federal courts. Before joining Holland & Knight, Sandra co-chaired a national law firm’s fraud and recovery practice group. She frequently speaks on insurance fraud and began her career as a prosecutor in Texas.

Learn More: https://www.hklaw.com/en/professionals/h/heller-sandra-l

Dan Silverboard

Partner

Dan.Silverboard@hklaw.com

Dan Silverboard is a healthcare attorney in Holland & Knight’s Atlanta office with over 20 years of experience in regulatory compliance and business transactions. He advises hospitals, physician groups, labs, pharmacies, and other providers on healthcare fraud and abuse laws, including the Stark Law and Anti-Kickback Statute, as well as Medicare reimbursement, licensure, and HIPAA compliance. Dan also counsels clients on contracts, joint ventures, acquisitions, and emerging AI regulations in healthcare. Before joining Holland & Knight, he practiced at a global law firm in Atlanta and remains active in the Anti-Defamation League and the Alliance Theatre.

Learn More: https://www.hklaw.com/en/professionals/s/silverboard-dan-moss

Holland & Knight Law: A Nationally Recognized Behavioral Healthcare Expert on Audits, Payment Integrity, and Compliance

Join us on Tuesday, November 11th, for an engaging ROC discussion with Sandy Heller and Dan Silverboard from Holland & Knight Law.

This session will unpack key legal and compliance issues affecting behavioral health providers today — including audit violations, payment integrity disputes, and the importance of partnering with regulatory experts to mitigate risk and protect revenue.

Holland & Knight is nationally recognized for its deep experience across the healthcare spectrum. As partners, Sandra Heller and Dan Silverboard leverage their strong relationships with regulators to help providers proactively shape and respond to compliance requirements. Their work centers on protecting providers’ rights, ensuring fair reimbursement, and supporting the long-term stability of behavioral health systems nationwide, while helping organizations get ahead of emerging trends and regulatory expectations.

Together, Sandy and Dan will also offer a preview of emerging compliance trends shaping 2025 and share practical steps providers can take now to prepare for upcoming industry shifts.

Sandra L. Heller

Partner

Holland & Knight

Sandra Heller is a South Florida attorney with a national practice focused on healthcare reimbursement disputes between providers and payers. She represents behavioral health facilities, hospitals, and health systems in resolving denied or delayed claims, maintaining payer relationships, and managing audits and investigations. A skilled litigator, she has extensive experience with ERISA cases, insurance fraud, and recovery actions in both state and federal courts. Before joining Holland & Knight, Sandra co-chaired a national law firm’s fraud and recovery practice group. She frequently speaks on insurance fraud and began her career as a prosecutor in Texas.

Learn More: https://www.hklaw.com/en/professionals/h/heller-sandra-l

Dan Silverboard

Partner

Holland & Knight

Dan Silverboard is a healthcare attorney in Holland & Knight’s Atlanta office with over 20 years of experience in regulatory compliance and business transactions. He advises hospitals, physician groups, labs, pharmacies, and other providers on healthcare fraud and abuse laws, including the Stark Law and Anti-Kickback Statute, as well as Medicare reimbursement, licensure, and HIPAA compliance. Dan also counsels clients on contracts, joint ventures, acquisitions, and emerging AI regulations in healthcare. Before joining Holland & Knight, he practiced at a global law firm in Atlanta and remains active in the Anti-Defamation League and the Alliance Theatre.

Learn More: https://www.hklaw.com/en/professionals/s/silverboard-dan-moss

Payor Behavior Updates

The Only Consistent in the Payor Landscape is Change.

A big thank you to Linda Shulman, Director of Payor Relations and Advocacy at Hansei Solutions, for an insightful discussion on what these payor changes mean for facilities, how to stay compliant, and strategies to protect revenue.

Key Topics Covered:

• Optum: New revenue codes for ASAM 4th Edition

• Ambetter: Billing must be submitted from admission to discharge only; telehealth for IOP is not covered

• California: CARF accreditation and state licensing challenges, especially for 3.7 levels of care

• General Trends: Inconsistencies between payor contracting and claims systems, updated billing practices to prevent denials, CMS guidelines, and federal prompt payment mandates

View Recording:

https://hanseisolutions.zoom.us/rec/share/PhHq9SuxoGNZctJHaV77aooeC0W7_EnYL3kCoNUp_yF2LVTLtC3SadZgvx9qj_vL.2mfyr9sVy07TS4xB

Passcode: wiqT5kS+

Highlights & Resources

ASAM Level of Care Certification

CARF-certified ASAM Level of Care (LOC) demonstrates a provider’s capacity to deliver residential substance use disorder treatment aligned with ASAM Criteria®. Certification differentiates providers to payers, regulators, referral sources, and patients.

• Available for adult Levels of Care: 3.1, 3.5, 3.7

• CARF is the only ASAM-approved certification program for residential SUD treatment

• Learn More

Cheat Sheet: Optum ASAM-4 Revenue Code Mapping

California DHCS Requirements & SB 823

All licensed adult AOD facilities must meet ASAM criteria or equivalent standards. Facilities can:

1. Obtain a DHCS Level of Care Designation, or

2. Secure ASAM LOC Certification via CARF, which satisfies DHCS requirements

Ambetter Billing Updates

Policy: Ambetter requires billing from admission to discharge only; interim billing for estimated charges is not accepted.

Why This Matters:

• Reduces administrative burden

• Minimizes denials for improper status billing

• Simplifies reconciliation
  

Recommended Workflow:

1. Admit the patient and begin inpatient services

2. Capture all services, diagnostics, room & board, and ancillary charges

3. At discharge, assemble a final UB-04 (or electronic equivalent) with:

   • Admit & discharge dates

   • Discharge status code

   • All charges and itemized service lines

4. Submit final claim to Ambetter

5. Respond promptly to any requests for additional documentation

And that’s all for this month. Join us on Tuesday, November 11th, for our next discussion!

Payor Behavior Update: Optum and ASAM 4th Edition & Ambetter Claims Cadence Changes

Behavioral health providers are facing upcoming shifts in payer behavior and billing requirements. OPTUM is transitioning to new revenue codes to align with the ASAM 4th Edition, while Ambetter now requires claims to be submitted from admission to discharge, where interim billing is not allowed.

Join us on Tuesday, October 14th, with Linda Shulman, Director of Payor Relations and Advocacy at Hansei Solutions, for an insightful discussion on what these payor changes mean for your organization, how to stay compliant, and strategies to protect your revenue.

We’ll cover:

• OPTUM’s shift to new revenue codes and billing rules under the ASAM 4th Edition.

• Ambetter’s no-interim-billing policy and its impact on billing cadence and cash flow.

• California Providers: Why investing in your CARF accreditation is now critical to get ASAM levels of care accredited—an upfront cost that can save you money long-term.

Linda Shulman

Director of Payor Relations and Advocacy

As the Director of Payor Relations and Advocacy, Linda brings her deep knowledge
and expertise to advance the organization’s mission. Linda is dedicated to
transforming how behavioral health services are reimbursed by engaging with
customers and insurance companies. She aims to develop inclusive, comprehensive
programming that shifts away from traditional, day-to-day utilization review (UR)
processes. Instead, she seeks to establish contracts focused on outcomes and
quality standards, helping to reduce readmissions, lower administrative costs, and
create meaningful, long-term care solutions for those in need. By advocating for
innovative reimbursement models, Linda is committed to making sustainable,
high-quality behavioral health services more accessible and impactful.

Linda Shulman, a licensed Marriage and Family Therapist with over 40 years of
experience, has held key roles, including the Director of Ventura County’s Behavioral
Health Department. She later moved into Utilization Management, providing UM
services remotely and founding a consulting business to support facilities with
accreditation and managed care. Her payor industry experience includes positions
at Aetna, Carelon, and Anthem, where she led the development of the Substance
Use Disorder Clinical UM Team.

Based in San Diego, Linda Shulman is a devoted single mother to her two adopted
children, a role she considers her full-time job. She’s an avid NFL fan and sports
enthusiast interested in travel, concerts, and movies.

September 2025: Getting the Right People in the Right Seats

How Strategic Talent Decisions Save You Money and Build Long-Term Success

In behavioral health, finding and keeping the right people is one of the biggest challenges organizations face. At our September 9th Masterminds session, we explored how hiring practices, the interview process, and employee satisfaction all tie directly to company reputation, operational efficiency, and long-term growth.

Thank you to our guest, Jordan Young, CEO & Founder of Jordan & Associates Consulting, for sharing real-world insights on recruitment strategies, compensation, advancement opportunities, and leadership’s role in building stronger teams and improving employee retention.

Missed the session? Watch the full recording here:

Https://hanseisolutions.zoom.us/rec/share/6g_iAgNgcjNb6AlCvBsSdK65Ku8m_lEGMWn8h_LtwtSliOFkpQA7SJWF4ILAxdVU.8nfmABF3HNJVPgpz?startTime=1757440188000

Passcode: P+6Ef0Ze

Industry Landscape & Hiring Trends

As the behavioral health field continues to grow, so does the competition for top talent. Job seekers now have more choices than ever, which means providers must sharpen their hiring strategies to attract and retain the right people.

📊 Key Insight from Jordan & Associates Healthcare Employee Survey: 78.3% of candidates who accepted a new role in the past year were interviewing with multiple companies.

What this means: The competition is fierce, and organizations must differentiate themselves with stronger recruiting practices, a clear value proposition, and a streamlined candidate experience.

The Interview Process: Getting it Right

A strong hiring process sets the tone for future success.

• Who’s involved: Interview panels should include people who know what success looks like in the role.

• Process clarity: Clearly outline steps and timelines to candidates.

• Decision-making: Avoid “consensus hiring.” As Jordan noted, “consensus is senseless.” Final decisions should rest with the right gatekeepers, not groupthink.

Training, Development & Retention

Hiring the right people is just the first step. To build lasting success, organizations must focus on what happens after day one—investing in training, development, and strong leadership to keep employees engaged and growing.

Why candidates choose one role over another:

• Company reputation (internal + external)

• Leadership and culture

• Clear training and development opportunities
  

  Why employees stay:

• Advancement opportunities (48%)

• Satisfaction with their current role (45.5%)

• Confidence in company direction (31%)
  

• 57% of employees rank compensation as the top factor in satisfaction.

• 61.4% of healthcare workers stayed with the same employer for a full year.

Real-World Lessons: The Cost of Poor Hiring

Insights are powerful, but the real impact comes through experience. Jordan shared case studies that reveal how poor hiring decisions can ripple across an organization—damaging reputation, straining operations, and creating costly setbacks.

• Reputation risks: Negative candidate experiences spread quickly in the close-knit behavioral health community.

• Operational drag: Hiring without clarity on role expectations leads to turnover, wasted resources, and misalignment.

• Leadership impact: Every interaction with candidates reflects leadership’s commitment to culture and vision.

Key Takeaways

✅ Hiring is competitive—clarity, speed, and reputation matter.
✅ The right interview structure ensures stronger long-term fits.
✅ Training and advancement opportunities drive retention.
✅ Poor hiring decisions are expensive—both financially and culturally.

The bottom line? Your people are your greatest asset—and your biggest expense if not managed strategically. By being intentional at every stage of the talent journey, organizations can protect their reputation, reduce costs, and create a strong foundation for growth.

Getting the Right People in the Right Seats: How Strategic Talent Decisions Save You Money and Build Long-Term Success

Real Cost-Saving Strategies Through Smarter Team Alignment

In the fast-changing world of behavioral health, one thing remains clear: your team drives your success — or your costs. At our September 9th Masterminds session, we’ll go beyond the basics to explore how strategic staffing can protect your reputation, reduce expenses, and fuel long-term growth.

We’re thrilled to welcome Jordan Young, CEO & Founder of Jordan & Associates Consulting, who brings over 15 years of hands-on experience helping behavioral health organizations scale effectively. Jordan will dive into real case studies that demonstrate the long-term consequences of poor operations — and how strategic, intentional staffing adjustment strategies can make a significant difference in every level of the business.

This session is a must for any operator seeking to reduce costs, establish a stable foundation, and stay ahead of industry trends.

🎯 You’ll walk away with:
✅ Real-world hiring mistakes that cost big
✅ Proven tactics to improve team alignment
✅ Key trends reshaping behavioral health operations
✅ Cost-saving strategies that don’t compromise quality

Because the right team isn’t just a cost center—it’s your greatest asset.

Learn About Jordan and Associates Consulting

Through years of working in behavioral healthcare, we’ve learned from and formed relationships with thousands of trusted contacts that serve treatment centers in all operational areas. Our mission is to turn your points of pain and angst into the most successful parts of your business that never cause you another sleepless night.

Jordan Young, C.E.O.

In 2010, Jordan’s personal recovery and desire to help others pushed him towards behavioral healthcare. He started in admissions, where he helped over 4,000 patients find treatment options that met their needs. In 2013, he was promoted to oversee the same organization’s events department, where he oversaw 17 national behavioral health conferences.

In 2018, Jordan’s aspirations to make a bigger impact on behavioral healthcare led to the creation of Jordan and Associates Consulting, whose purpose is to leverage the experience, education, and thousands of connections made in the industry to help treatment centers overcome obstacles blocking their path to success. Jordan’s 15 years of experience and thousands of relationships in behavioral healthcare have formed the foundation for the focus of his business, which is helping treatment centers hire key staff. He has worked with over 50 different behavioral healthcare organizations to identify, interview, and hire key staff in Executive, Business Development, Admissions, Revenue Cycle Management, Marketing and Operations positions.

July 2025: The Payor Games You Didn’t Sign Up For

Payor Pressure Points – Parity, Ghost Networks & Other Hidden Hurdles

In July’s Masterminds discussion, we took a hard look at the escalating pressure points facing mental health and SUD providers in today’s payor landscape. Erin Burke (CEO, Hansei Solutions) and Christopher A. Parrella, Esq. (Founder, Parrella Health Law), peeled back the curtain on the latest tactics used by insurers to delay payments, bury provider networks, and block access to fair reimbursement.

View Recording

Passcode: ^LL$6Lfd

✅ Action-Oriented Takeaways

• Map the Ghost Network: Call listed providers, confirm operational status, track bed availability, and use that data to compare across payors.
  

• Document, Don’t Delay: Proactively compile evidence of network inadequacies and parity violations before denials start stacking up.
  

• Challenge Ambiguity: Consider whether declaratory actions may help bring clarity to recurring issues like detox level designations.
  

• Use Your Voice: Silence is a tool used by payors—push back early and often. Even if it feels like you’re beating a dead horse.

What We Covered

🕵️ Ghost Networks
A deep dive into payor directories revealed a troubling reality: many listed providers are not actually credentialed, operational, or accessible. A case study out of Tennessee exposed how 14 payors claimed access to 140 beds—but only 10 providers actually offered them. Attendees stressed the need for data-driven audits to expose these inaccuracies and demonstrate true network adequacy.

💰 Payor Playbooks Decoded
From overpayment demands and federal recoupments to slow-walked credentialing and pre-payment reviews, providers shared how these tactics are used to withhold revenue or retroactively claw it back. Misaligned sub-acute detox authorizations and inconsistent ASAM level designations—especially in states like California—were flagged as ongoing hurdles.

📉 Key Updates from Tricare, Anthem, and TriWest
We also examined reimbursement slowdowns and contract challenges tied to several large payors. Delays in rate negotiations and shifting criteria—such as requirements for CARF accreditation—are having a direct impact on cash flow, particularly for detox and residential levels of care.

🔍 Parity Violations
We discussed real-world examples of how to use the Parity Act as more than a compliance requirement—it’s a tool to fight back when behavioral health care is sidelined. Legal strategies like declaratory actions were mentioned as a way to prompt policy clarification and challenge treatment denials.

Final Thoughts

This session wasn’t just about surfacing frustrations—it was about equipping providers with practical tools to push back. Whether you oversee clinical operations, handle billing, or manage compliance, these insights are essential to protecting both revenue and patient access.

Erin Burke

CEO & Founder

Hansei Solutions

erin@hanseisolutions.com

Christopher A. Parrella, ESQ., CPC, CHC, CPCO

Health Care Provider Defense and Compliance Attorney

Parrella Health Law

cparrella@parrellahealthlaw.com

Payor Pressure Points: Parity, Ghost Networks & Other Hidden Hurdles

Unpacking Payor Barriers and What They Mean for Your Operation

Intro: A Quick Look Back

In our May Discussion, we welcomed Erin Burke (CEO & Founder, Hansei Solutions) and Chris Parrella (Healthcare Defense & Compliance Attorney, Parrella Health) to dive into some of the industry's most avoided—but most critical—topics:

• Legal exposure

• Broken contracts

• Inconsistent payments

Part Two: Join us on Tuesday, July 8th

The conversation sparked powerful questions we didn’t have time to fully explore—so we’re continuing the discussion on Tuesday, July 8th from 11am - 12pm PST on Zoom.

The payor landscape is shifting fast—and behavioral health & SUD providers are feeling the squeeze. Join industry insiders Erin Burke (CEO, Hansei Solutions) and Christopher A. Parrella, Esq., CPC, CHC, CPCO (Parrella Health Law) for an unfiltered hour on the tactics that stall payments, derail care, and keep you fighting for every dollar.

What we’ll unpack

• Parity Violations – real-world appeal wins & how to weaponize the Parity Act

• Ghost Networks – inaccessible directories that hide in plain sight

• Credentialing & Rate-Negotiation Battles – strategies to secure fair contracts

• Payor Tactics – overpayments, refund demands & pre-payment reviews decoded

• Tricare, Anthem & TriWest Updates – what’s changing and how it hits your bottom line

Why You Can’t Miss It

1. Cut through denial smoke-screens before cash-flow stalls.

2. Hear proven counter-moves from providers who’ve already scored payor concessions.

3. Walk away with actionable playbooks you can deploy the same day.

Have a burning question or new buzz to dissect?

Drop it anonymously here and we’ll tackle it live: https://form.jotform.com/251196626159161

Mark your calendar and come prepared to challenge the payor status quo. Be sure to share this with your revenue cycle, clinical, and executive teams—anyone ready to put an end to payor run-arounds.

Tuesday, July 8 | 11:00 AM – 12:00 PM PT | Live on Zoom

Add to Calendar

📢 June Break – ROC Returns in July with Hot Topics & Critical Payor Insights

We’re taking a short pause in June to reset and prepare for a powerful second half of the year.

🔜 Coming in July:
We’ll be back with a fresh ROC Meeting focused on critical issues reshaping behavioral health reimbursement:

• New Payor Policy Changes: What’s shifting and how to stay ahead

• Ghost Networks: The truth behind inaccessible directories and patient barriers

• Parity in Behavioral Health: Where the gaps still exist—and what advocacy looks like now

📅 More details coming soon. Enjoy the month of June. We’ll see you in July, and we're ready to dive back in.

May 2025 Masterminds Recap: What’s Really Going On with BCBS Oklahoma, Tricare, the VA, and Ambetter?

In our May Masterminds session, we tackled the tough topics too often left out of the spotlight—yet central to the operational reality of behavioral health providers today.

View Recording:

https://us02web.zoom.us/rec/share/Y--yEXkdkkzXlKPEZv8FGlZL4L2SEQ6WMrmz8beubwCxdyS0x1ndKCztGoUeLcqt.NRJ1jj88K0dRKeI8

Passcode: 2hviFX$7

Hosted by Erin Burke, CEO & Founder of Hansei Solutions, and Christopher Parrella, a leading healthcare defense and compliance attorney, the discussion focused on helping operators understand their risk and prepare for what’s next in an increasingly hostile payor landscape.

Navigating Payor Chaos

In the ever-evolving world of behavioral healthcare, providers continue to face immense complexity when it comes to billing compliance, legal risk, and reimbursement disputes. Erin and Chris unpacked the growing gray areas in payor behavior—particularly around TRICARE audits, type-of-bill discrepancies, and systemic issues with Ambetter.

TRICARE, Audits, and the Burden of Clarity

TRICARE’s recent surge in audits has placed a spotlight on how providers are expected to navigate "prescribed conduct" without clear direction. If a provider receives guidance from a manual or coverage criteria and fails to comply, payors may claim breach and seek repayment. But when that guidance is vague—or missing altogether—there may be strong legal defenses such as “without fault” or “waiver of recovery.”

Especially when billing doesn’t misrepresent place of service, and no contract or manual spells out a different expectation, providers can and should appeal such recoupments.

As Chris noted, “Some of this stuff isn’t binary… claims systems were built long ago and aren't easy to change. The way payors recognize providers often doesn’t align with the reality of care delivery.”

To navigate these challenges, providers can take several legal actions.

Legal Defenses and Strategic Responses:

• Providers may use defenses such as "without fault" and "waiver of recovery" if unclear guidance or ambiguous contracts led to billing practices that violated a payor’s coverage policy.

• These defenses are especially relevant when there was no intent to deceive.

• They are useful for dealing with recoupments stemming from outdated billing systems and lack of clear instructions.

Federal vs. Commercial Payors:

• Providers must be cautious when dealing with federal payors like TRICARE or the DOD.

• Federal payors can impose broader consequences, including DOJ referrals, compared to commercial payors.

• Commercial payors typically have narrower enforcement options (e.g., internal review or civil lawsuits).

Legacy Systems and Billing Confusion:

• Many legacy claims systems misalign with actual care delivery, creating confusion.

• Some payors still require inpatient-type UB04 forms for PHP/IOP claims, despite the billing not being technically accurate, due to outdated and hard-to-update systems.

Ambetter: Chaos at Scale

No payor sparked more frustration in the discussion than Ambetter. From incorrect provider onboarding to inconsistent claim processing across states, the issues span multiple levels of care and administrative failures. In Tennessee, providers are improperly loaded as professional groups and forced to bill on forms that don’t reflect the services provided. In other states, identical services are processed correctly.

Ambetter’s rapid expansion has overwhelmed its infrastructure, creating widespread delays, misconfiguration, and a rotating door of reps.

The advice?

Go upstream: Approach Centene's general counsel directly rather than working through Ambetter for faster resolution.

Avoid costly and slow lawsuits: Lawsuits can be time-consuming and expensive.

File Department of Insurance complaints cautiously: Keep in mind, these may not yield quick results.

Present clear chronologies: Provide organized, detailed information with reference numbers to facilitate resolution.

Escalate at the parent-company level: Raising issues at the parent-company level can lead to more feasible resolutions.

Understanding Who Really Holds the Keys

Another recurring theme: Providers often hit dead ends because they’re knocking on the wrong doors. In Georgia, a provider was repeatedly denied by Anthem—until it was discovered that contracting was handled by Carelon. After escalating to the Georgia Department of Insurance and bringing network adequacy into question, the provider was finally accepted.

This brings us to a critical lesson: Know the full payor ecosystem. “Understand if the payor is using a third party, a subsidiary, or another entity for credentialing and contracting,” our experts advised. “And don't assume you're dealing with the right party just because of the logo on the EOB.”

Industry-Wide Lessons

• Know the Ecosystem: When denied access or stuck in credentialing negotiations, consider whether the payor has outsourced responsibilities to another party.

• Ghost Networks: This is a growing federal and political concern, where published directories show inaccurate provider participation. This ties into broader parity violations and network adequacy failures—potential topics for future legal and strategic discussions.

What Comes Next?

From ghost networks to parity violations and abrupt reimbursement shifts for out-of-network claims, there’s much more to unpack in future conversations. But the message from this one is clear: In behavioral health, where guidance is often outdated or incomplete, providers must stay vigilant, document everything, and know where to apply pressure to protect revenue.

Whether it's appealing audits, escalating onboarding failures, or tracking network adequacy, success depends on understanding the systems—not just the symptoms—and being unafraid to challenge the status quo.

Erin Burke

CEO & Founder

Hansei Solutions

Christopher A. Parrella, ESQ., CPC, CHC, CPCO

Health Care Provider Defense and Compliance Attorney

Parrella Health Law

What’s Really Going On with BCBS Oklahoma, Tricare, The VA, and Ambetter?

We’re diving into the topics many in our industry avoid — the ones that matter most to operators navigating today’s complex payor environment: legal exposure, broken contracts, and inconsistent payments.

Join us on Tuesday, May 13th, as Erin Burke, CEO & Founder of Hansei Solutions, and Chris Parrella, Health Care Provider Defense and Compliance Attorney at Parrella Health Law, break down what’s behind the headlines — and what you can do next.

Have questions or concerns you'd like us to address? Submit them anonymously ahead of time:

Submit Questions Here

Providers are navigating a wave of uncertainty. What We’ll Break Down:

• Ambetter payment disruptions tied to centralized claims processing and broken legacy agreements

• BCBS Oklahoma lawsuits and potential provider exposure

• VA and Tricare refund demands and payment discrepancies

• Marketplace guidance—what can be said during admissions calls

• Coding and Reimbursement Tactics: What’s Smart vs. What’s Risky

• New rate structures from Ambetter, VA, and Cigna for detox/residential

April 2025: DOJ’s Case Against Claritev (MultiPlan)

This month’s ROC Meeting focused on one of the most significant legal developments impacting healthcare providers in 2025: the Department of Justice's intervention in the antitrust lawsuit against Claritev (formerly MultiPlan). The case centers around allegations that Claritev, in collaboration with major insurers, leveraged a common pricing algorithm to coordinate reimbursement rates—potentially constituting price-fixing and violating federal antitrust laws.

A huge thank you to Erin Burke, CEO & Founder of Hansei Solutions, and Matt Lavin, Healthcare Litigation Attorney and Partner at Arnall Golden Gregory, for joining us to unpack the implications of this case and what providers should be doing now to protect themselves.

🎥 Missed the meeting? View the recording:

https://us02web.zoom.us/rec/share/s9kqQhL1ZDDKVOrbtg5aRfPkKWFeeap4DlUNXXit67w9yWT2ngUUxxnkX07L3Vlc.-YnwDZOALaTiZvSF

Passcode: aK6=$5Fq

🔍 Overview of the Case: MultiPlan Becomes Claritev

MultiPlan’s Transition to Claritev​

🔹 MultiPlan has officially rebranded as Claritev​

🔹 The goal: Enhance clarity & innovation in healthcare​

​

What this means for providers:​

✅ Name change only—MultiPlan has not been sold​

✅ No impact on contracts, pricing, or existing services​

✅ Provider agreements remain valid (future amendments will reflect Claritev)​

✅ No immediate changes to contact info, provider portals, or ID cards

⚖️ DOJ Intervention: What It Means for Providers

The DOJ’s involvement underscores growing federal concern over algorithmic pricing tools being used to coordinate payor decision-making. The case points to broader industry issues:​

🔹 Increased scrutiny on payor-provider dynamics​

🔹 Risks of financial recoupments & reimbursement challenges​

🔹 Tactics framed as “opportunities” but may undermine providers

📄 FAQ & Legal Resources

Matt Lavin and his team at AGG have put together a helpful FAQ sheet on the case.

View FAQ Sheet Here

Still have questions? Reach out directly to:

• Matt Lavin – Matt.Lavin@agg.com

• Kiera Gwynn – Kiera.Gwynn@agg.com

✅ Provider Action Items

• Stay informed about the DOJ’s case and evolving legal landscape

• Contact regulators regarding concerns around network adequacy and underpayment

• Reach out to Kiera or Matt about joining the MultiPlan litigation or resolving related disputes (prepayment reviews, denials, recoupments)

We'll continue monitoring this case and sharing updates in future ROC meetings. If you're experiencing any payer-related issues that feel aligned with this case, don't wait—reach out for support and legal guidance.

📚 Additional Reading

• The Register: DOJ Backs Multiplan Antitrust Case

• Healthcare Dive: DOJ Supports Provider Suit Against Claritev

Erin Burke

CEO & Founder

Hansei Solutions

Matt Lavin

Healthcare Litigation Attorney & Partner

Matt.Lavin@AGG.com

Arnall Golden Gregory

Kiera Gwynn

Attorney

kiera.gwynn@agg.com

Arnall Golden Gregory