Behavioral health continues to be shaped by expanding access, evolving care delivery models, and regulatory change. While these advancements have improved patient access to critical services, they have also introduced new complexities for payers working to maintain program integrity and reduce fraud, waste and abuse (FWA) risks.<\/p>\n
For health plans, particularly those serving Medicaid and other government-sponsored populations, identifying emerging billing patterns, strengthening review processes, and aligning internal teams around consistent standards can help reduce financial leakage while supporting appropriate care delivery.<\/p>\n
The shifting critical behavioral health trends<\/h2>\n
Increased adoption of telehealth, the integration of behavioral services into primary care, and the expansion of digital treatment tools have fundamentally changed how care is delivered and billed. These changes have also created new opportunities for inconsistent billing practices and documentation gaps.<\/p>\n
Telehealth has played a central role in this evolution. What began as a temporary solution during the COVID-19 pandemic has become a permanent fixture in behavioral healthcare. Patients increasingly rely on remote services, and providers have adapted their workflows accordingly. However, this shift introduces additional complexity for payers, particularly when it comes to verifying that services were delivered as billed and appropriately documented.<\/p>\n
Claims data analyzed by Cotiviti also reveals a growing trend toward higher-intensity services. Longer psychotherapy sessions are now billed far more frequently than shorter visits. While this may reflect legitimate clinical needs in many cases, the consistent use of the highest-level codes across large portions of a provider\u2019s claims can signal potential overutilization or inappropriate coding behavior.<\/p>\n
![\"0726_Blog_Behavioral](\"https:\/\/blog.cotiviti.com\/hs-fs\/hubfs\/0726_Blog_Behavioral%20health_Figure%201.png?width=873&height=642&name=0726_Blog_Behavioral%20health_Figure%201.png\")
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Figure 1. \u00a0Behavioral telehealth claim trends, 2019\u20132024.<\/p>\n
High-risk service areas in behavioral health<\/h2>\nPsychotherapy<\/h4>\n
Certain service categories consistently present higher risk for improper billing. Psychotherapy services, particularly those billed at the highest duration levels, are a clear example. In many reviews, 60-minute sessions dominate provider billing patterns with little variation. While this may occasionally be appropriate, a lack of variability can raise questions about whether services are being accurately represented.<\/p>\n
ABA therapy<\/h3>\n
Applied behavioral analysis (ABA) therapy is another area that requires careful attention. Commonly used to treat individuals with autism, ABA\u2019s \u00a0intensive nature, reliance on multiple providers, and time-based billing structure create opportunities for both documentation issues and inappropriate billing.<\/p>\n
In one Cotiviti prepay investigation, a provider was identified through analytics as having unusually high utilization of ABA therapy services. Red flags included:<\/p>\n
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Consistently billing excessive daily hours that did not align with clinical feasibility, especially when accounting for travel time, documentation requirements, and realistic patient schedules<\/p>\n<\/li>\n
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Significantly higher billing patterns than peers<\/p>\n<\/li>\n
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Time-related anomalies, including frequent weekend billing and patterns that did not align with typical ABA delivery models<\/p>\n<\/li>\n
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Billing well above CMS medically unlikely edit (MUE) thresholds, which are designed to prevent excessive or inappropriate unit billing<\/p>\n<\/li>\n<\/ul>\n
Before initiating prepay review, a license verification revealed a critical issue: the provider began billing nearly a year before their license became active. This alone warranted immediate escalation.<\/p>\n
Once medical records were requested, the documentation confirmed the risks identified in the data. Records frequently lacked required components or sufficient detail, and consent documentation was either missing or inconsistent. In some cases, consent forms were signed by individuals who were not authorized guardians. One of the most concerning findings was the repeated use of cloned or templated notes, with similar language appearing across multiple patients. This pattern strongly indicated a lack of individualized care documentation and raised questions about the legitimacy of the services billed.<\/p>\n
As prepay denials began to occur, the provider shifted billing to different codes that had not yet been flagged. This behavior underscored the value of prepayment controls as it allowed for rapid expansion of review parameters and prevented further improper payments. During discussions, the provider also indicated a willingness to modify documentation to ensure payment, raising serious concerns about potential record falsification.<\/p>\n
Ultimately, the provider was removed from the network, and more than $100,000 in improper payments were avoided within a short review window. This case illustrates the effectiveness of prepayment strategies in identifying and stopping problematic billing early, before significant financial exposure occurs.<\/p>\n
New reimbursement models and emerging risks<\/h2>\n
The shift toward value-based care and integrated service delivery has introduced new billing frameworks in behavioral health. Behavioral health integration (BHI) services now allow providers to coordinate care across disciplines and receive reimbursement for those efforts. While these models promote better patient outcomes, they also increase the complexity of billing and documentation.<\/p>\n
Challenges can arise when providers bill add-on codes without the required base services or when incompatible services are reported within the same time period. In addition, documentation must clearly demonstrate collaboration among care team members, including evidence of coordination and communication. Without this level of detail, it becomes difficult to substantiate claims, increasing the risk of improper payments.<\/p>\n
As new codes and service structures are introduced, payers must remain proactive in updating their review logic, educating providers, and monitoring emerging trends.<\/p>\n
An action plan for payers<\/h2>\n
In the near term, plans should focus on identifying high-risk providers and services by analyzing billing patterns and outlier behavior. This includes evaluating whether current prepay and postpay controls adequately address areas of vulnerability.<\/p>\n
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\n Near-term<\/strong><\/th>\n Next 90 days<\/strong><\/th>\n Next 90\u2013365 days<\/strong><\/th>\n<\/tr>\n \n \n - \n
- Prioritize high-risk behavioral health services and providers\u00a0<\/li>\n
- Assess current claim review coverage<\/li>\n<\/ul>\n<\/td>\n
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- Analyze providers\u2019 billing patterns<\/li>\n
- Align clinical, coding, SIU, and network stakeholders<\/li>\n<\/ul>\n<\/td>\n
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- Enhance data integration across services<\/li>\n
- Standardize review pathways by service type and complexity<\/li>\n
- Continuously refine clinical and coding review logic<\/li>\n
- Drive sustainable compliance and provider engagement<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/div>\n
Advancing program integrity in a changing environment<\/h3>\n
As behavioral health continues to evolve, so must the strategies used to safeguard it. The combination of advanced analytics, clinical expertise, and coordinated program integrity efforts enables payers to identify risks earlier and intervene more effectively. By focusing on both prevention and detection, organizations can reduce improper payments while supporting high-quality, appropriate care for their members.<\/p>\n
\nWebinar: Behavioral health FWA trends, risks, and strategies<\/h3>\n
Watch as Cotiviti\u2019s behavioral health and FWA experts discuss:<\/p>\n
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The latest guidance designed to stop Medicaid fraud and abuse<\/p>\n<\/li>\n
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How emerging behavioral health trends are being exploited by bad actors<\/p>\n<\/li>\n
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Key takeaways from the recent federal release of behavioral health provider data<\/p>\n<\/li>\n
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Tools and approaches to identify and stop FWA without creating provider abrasion<\/p>\n<\/li>\n<\/ul>\n
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![\"Watch](\"https:\/\/no-cache.hubspot.com\/cta\/default\/394315\/interactive-213624317609.png\")