November 2025: Trends In Payor Disputes and the Interplay of Regulatory and Compliance
Holland & Knight Legal Insights
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
The takeaway: a robust, proactive compliance program is no longer optional. It should be designed around your actual risk profile, not just a generic policy binder on a shelf.
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
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.Control your submission process
Document exactly what you send and when.
Use organized, complete packages.
Keep proof of transmission and receipt.
Track outcomes and deadlines
Calendar appeal windows and expected decision dates.
Follow up when payors miss their own timelines.
Use provider education meetings
When available, request provider education sessions to clarify expectations, dispute mischaracterizations, and establish a record of good-faith engagement.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 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 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