Detecting Behavioral Health Fraud: How Health Plans Can Strengthen Their Approach

As behavioral health claim volumes continue to increase, there’s a growing need for health plans to be vigilant in spotting fraud, waste and abuse. Today, the complexity and cost of these schemes necessitate a proactive, preventative approach.

Nearly four out of five psychologists say they are seeing increased volumes of patients experiencing anxiety, while two out of three reported an increase in symptom severity in 2022, an American Psychological Association survey shows. High volumes, combined with new modes of care delivery approved during the pandemic such as audio-only services for behavioral health, make these services especially vulnerable to fraud, waste and abuse by bad actors.

Some health plans—typically larger plans with greater resources—have large in-house special investigations units with the expertise to review behavioral health claims data for suspicious activity. One investigation detected more than 40 dates of service for which a provider billed more than eight hours of services a day, often on consecutive days, including major holidays such as Thanksgiving, Christmas and New Year’s Day. A closer look at the documentation revealed inconsistencies in the member’s identity, age, gender, health history and sexual orientation. These were signs that services might not have been provided or that records were being cloned, with either scenario leading to inappropriate payment. Without this investigation, the health plan could have overspent as much as $115,000 annually on just one provider’s claims.

But not every plan has access to a large SIU to combat fraud, waste and abuse in behavioral health. That’s why knowing how to decrease the risk of inappropriate claim payment—preferably before the claim is paid—is an important step toward improving payment integrity.

Behavioral Health Schemes Are Increasing

The potential for lost revenue is high in an environment like the one health plans found themselves in during the COVID-19 pandemic when the need for services like behavioral health dramatically increased, but opportunities for in-person care suddenly shrank. 

The relaxations in telehealth delivery that occurred during the pandemic, for example, created additional avenues for bad actors to exploit members who badly needed mental healthcare. Suddenly, Medicare members could access behavioral health via telehealth using audio-only communication platforms, from the point of the first visit. They could also access care via telehealth from providers across state lines, whether in their homes or in rural health clinics or federally qualified health centers. Many of these changes became permanent for Medicare, such as enabling beneficiaries to receive behavioral telehealth services in their home. Others have recently been extended for several months beyond the expiration of the COVID-19 public health emergency (PHE), such as flexibilities that enable providers to prescribe controlled medications via telehealth. 

Individual psychotherapy sessions are another area that is ripe for fraud, waste and abuse. Among claims processed by Cotiviti, 60-minute individual therapy sessions comprised nearly two-thirds of behavioral health procedure codes in 2022. One example of potential waste and abuse is when a higher-than-average percentage of claims are billed as 60-minute sessions compared with a provider’s peers, warranting a closer look. Then there’s applied behavior analysis services for people with autism, an area where disreputable providers have submitted false claims, upcoded claims, or billed for one-on-one therapy rather than a group session. In one instance, the U.S. Attorney’s office recovered more than $2 million from an autism therapy provider for false claims. 

Yet many plans are hesitant to pursue suspected issues with behavioral health claims. There is a tendency to treat these claims more sensitively than other types of claims, partly due to fears of upsetting members who need mental health care and partly due to a lack of in-house expertise—from clinicians to coders—to review these claims. Moreover, patients who are most often targeted in these schemes include those least likely to review or understand their claims—such as the elderly—as well as those who suffer from addiction and those whose claims are fully covered by insurance.   

Detecting Behavioral Health Schemes Faster

When behavioral health claims look suspicious or outright wrong, the right defense helps plans protect themselves as well as their members—and prevents these cases from continuing to proliferate. Here are ways health plans can shore up efforts to prevent and detect behavioral health fraud, waste and abuse.

1. Become well-versed on the changes in behavioral health service delivery that will become permanent. This includes knowing which telehealth flexibilities continue to be extended following the expiration of PHE—and in what circumstances. This will help in educating providers, members and staff on what has changed in the plan’s coverage of remote behavioral health services. It will also position payers to take the first steps toward optimizing prepay claim editing.
2. Take a proactive approach to data mining, looking for trends in behavioral health spending. Examine trends in behavioral health spending prior to the pandemic and compare them to the types of claims the health plan is seeing now. Look at providers that are rendering much of their services in a telehealth setting and that are expanding their geographic coverage area. This data offers a basis for flagging providers that warrant immediate investigation.
3. Go beyond a traditional outlier analysis. Outlier analysis can position plans to pick the low-hanging fruit, such as providers who are billing extremely high volumes. But with these schemes becoming more sophisticated, health plans should also examine trends such as clustering—when a group of providers in a geographic area provides similarly high volumes of behavioral health services. They should also compare providers’ activity levels to those of their peers, regionally and nationally. Doing so can help pinpoint providers that are flying under the radar and merit a second look. Today, the addition of artificial intelligence algorithms and machine learning is assisting health plans in moving from retroactive, “pay-and-chase” review toward early detection of inappropriate claims.
4. Adopt a collaborative approach to front-line detection of suspicious claims. For small and medium-sized plans in particular, talking with other plans about the trends they are seeing in the same geographic area can uncover regional trends that deserve greater focus. This gives health plans a better basis for determining where to devote resources for strengthening prevention and recovery. It also increases staff productivity by empowering them to catch bad billing behaviors before payment is made.
5. Add prepay and postpay integrity solutions to your revenue integrity toolkit. This not only enables plans to detect behavioral health schemes faster, but also positions them to use the learnings from their investigations to optimize prepay claim editing moving forward.

Prevention Starts with a Change in Mindset

The sophistication of behavioral health billing schemes calls for health plans to let go of their fear of pushing back on behavioral health claims and arm themselves with actionable data and expert guidance. Such an approach empowers plans to more effectively detect and analyze suspicious claims, catch red flags and follow up on potential patterns of abuse, protecting vulnerable members.

About Erin Rutzler

Erin Rutzler is vice president of fraud, waste and abuse for Cotiviti. As vice president of fraud, waste, and abuse (FWA), Erin is responsible for the oversight and strategic direction of Cotiviti’s FWA solution suite. In her role, Erin has been integral in the development of Cotiviti’s FWA solutions over the past eight years. Serving as the company’s primary subject matter expert in investigations and FWA for compliance, client training, sales, and marketing activities, she regularly represents the company at industry conferences such as the National Health Care Anti-Fraud Association’s (NHCAA) Annual Training Conference (ATC).

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