May 2025: The Conversations No One Wants to Have
What’s Really Going On with BCBS Oklahoma, Tricare, The VA, and Ambetter?
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.
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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They are useful for dealing with recoupments stemming from outdated billing systems and lack of clear instructions.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.
Have any additional questions specific to your company?
Submit them in this form, or contact Erin or Chris.
Erin Burke
CEO & Founder
Christopher A. Parrella, ESQ., CPC, CHC, CPCO
Health Care Provider Defense and Compliance Attorney