June 2026: Protect Your Revenue — The R.I.S.E. Series (Enforcement & Rights)
Part 4 of a 4-Part Series for Behavioral Health Facility Owners | April–July 2026
Enforcement & Rights
Your regulatory rights. How to fight back when a payer denies or audits you. SB 855 protections, independent medical review, and how to hold everyone accountable.
View Recording: https://hanseisolutions.zoom.us/rec/share/FyT_rIhFCcqgfrV0l06M08lUBwOtrWcYnMj85Fk1qWnSWPrE8dfGY5n_x4gQ94Fv.GKeyT6ydXtT4mMgf Passcode: y0*CWZQF
Behavioral health providers are up against a lot: shifting regulations, aggressive payer tactics, and audits that can feel impossible to navigate without the right playbook. That’s exactly what this month’s ROC Masterminds session tackled — arming providers with the regulatory knowledge and practical strategies they need to protect their revenue and hold payers accountable.
Jenna Joneikis, Senior Integrity Analyst at Hansei Solutions, led the discussion, which covered everything from documentation best practices to the escalation path for a denied claim. Here’s a recap of what was discussed, plus a resource list for anyone looking to go deeper.
The Big Picture: Documentation and Staying Current
Jenna opened with a theme that ran through the entire session: detailed documentation is your first line of defense. Coding and billing requirements change constantly, and providers who aren’t actively tracking those changes are exposed — even when they’re getting paid.
That last point is worth repeating: getting paid today doesn’t mean you’re safe tomorrow. Recoupments and post-payment audits can claw back revenue long after a claim has cleared, which is why staying current on coding guidance isn’t optional — it’s risk management.
Know Your State’s Regulations
Regulatory protections for behavioral health claims vary significantly by state, and providers need to know what applies to them specifically:
Federal parity protections (MHPAEA) set a baseline for what behavioral health claims are guaranteed — but state-level laws can go further.
California’s SB 855 was highlighted as a strong example of state-level protection, along with the state’s 30-day readmission rule.
Providers in other states (Georgia and beyond) were encouraged to check whether similar protections exist where they operate. Not every state has an equivalent, and assuming your state offers the same protections as California can be a costly mistake.
Independent Medical Review (IMR): What It Is and When to Use It
A significant portion of the session was dedicated to demystifying the IMR process:
What it is: When a payer continues to deny a claim, an IMR allows you to request review by an unbiased, third-party physician — essentially a check on the payer’s decision.
Who can request it: IMRs are typically driven by the patient, initiated independently.
Escalating on a patient’s behalf: If a provider wants to escalate an IMR for a patient, written patient consent is required — this isn’t something providers can initiate unilaterally.
The escalation path: Appeal → IMR → regulatory complaint. Knowing this sequence — and when to move to the next step — is key to fighting back effectively.
Know Your Audit Rights
Audits are one of the most stressful parts of running a behavioral health practice, and the group discussed the importance of knowing exactly where the line is:
What payers can and cannot legally demand during an audit
What counts as a reasonable response timeline
The difference between self-funded vs. fully funded plans, and why that distinction matters for how ERISA applies to a given case
Coding: Defensible vs. Risky
Where’s the line between being appropriately aggressive with coding and being exposed to risk? The group’s guidance was simple: don’t guess. If there’s ambiguity, get it right the first time rather than hoping it holds up later. A running resource list was recommended to help providers stay current on coding standards.
Choosing Your Battles: When to Push vs. When to Let It Go
Not every denial is worth fighting, and part of building a sustainable revenue cycle strategy is knowing which ones are. The group discussed evaluating:
Overpayments and underpayments — and how each should be handled differently
Which denials have a real path to reversal versus which ones cost more in time and resources than they’re worth
What’s Next
Future Masterminds sessions will continue to dig into these themes, with a focus on improving provider-payer relationships and giving providers more tools to navigate audits and denials with confidence.
Action Items From This Session
A full list of key takeaways and regulatory/coding resources — including the state-specific materials requested during the session — will be compiled and shared with all attendees.
Providers are encouraged to review their own state’s parity and readmission protections and compare them against California’s SB 855 as a benchmark.
Have questions about navigating payer denials, audits, or IMRs for your organization? Reach out — this is exactly the kind of work we help behavioral health providers with every day.