Behavioral health is no longer an afterthought in healthcare—it’s central to how people heal, how systems function, and how payers drive value. From anxiety treatment to substance use recovery, behavioral health services support holistic care and make meaningful differences in both short- and long-term outcomes. Payers know this. Providers know this. And, increasingly, members are demanding it.
In a post-pandemic landscape shaped by heightened awareness and rising demand, the number of behavioral health claims is growing rapidly. According to a study from LexisNexis, behavioral health claims rose 83% from 2019 to 2023. That surge isn’t just from increased demand, it’s from a greater understanding of the truth: mental health matters.
But, even as this evolution brings better access and awareness, it also brings complexity into the healthcare ecosystem. As behavioral health solidifies its rightful place in mainstream care, it’s also driving a reevaluation of how payment integrity must evolve.
Behavioral Health is a Systemic Driver
Payers face a dual challenge: support this critical care need and safeguard against misuse, inefficiency, and administrative waste. To do that well, payment integrity programs need to treat behavioral health not as a special case, but as a core pillar of holistic member care.
From ER visits to medication adherence to chronic condition management, the presence—or absence—of behavioral health support ripples across the system. That’s why leading payers are no longer treating it as a siloed line item, they’re tracking its impact across their entire book of business.
A landmark 2020 Milliman study paints a clear picture:
- 57% of high-cost members have a behavioral health diagnosis
- Just 5.7% of 21 million people studied accounted for 44% of total healthcare costs
- These members average $45,782 annually in healthcare spend
- Their medical/surgical costs are 2.8 to 6.2 times higher than average
Behavioral health is a structural cost driver, and, until it’s treated with the same operational rigor as surgical or pharmaceutical care, payers will continue to feel the strain.
Legacy Tools Weren’t Built for Behavioral Health
Behavioral health claims have increased rapidly and the legacy tools and processes payers have historically relied on aren’t able to assess these claims effectively or efficiently. Traditional cost containment tools simply weren’t designed for the nuances of behavioral health. Combined with manual reviews and rigid rulesets, critical context is often missed when it comes to assessing these claims.
Not only are the processes outdated, but mental health and substance use cases are inherently complex—often coded differently, delivered by varied provider types, and deeply rooted in longitudinal care needs.
This isn’t an opinion. We’re seeing it in the data:
- CPT 90847 (family/couples therapy) is trending upward, especially in pediatric and substance use disorder (SUD) settings
- Claims from non-licensed or uncredentialed providers are slipping through and risking compliance
- Urine drug testing, when done repeatedly without cause, is inflating costs with little clinical value
With urine testing, for example, some providers bill both presumptive and definitive tests on the same day for a single urine sample—or default to the highest-paying panel codes without medical justification.
This uptick in behavioral health utilization isn’t inherently problematic. In many ways, it reflects long-overdue progress toward more comprehensive care. To reduce risk for payers and improve the quality of care for patients while eliminating stress on providers, however, everyone needs to be on board with adopting more modernized tools.
Payment Integrity for a New Era: From Oversight to Foresight
Supporting behavioral health means building payment integrity systems that understand behavioral health. The COVID-19 pandemic accelerated demand, but outdated systems still lag behind. What’s needed is a transformation—not just in tools, but in mindset.
With the prevalence of behavioral health claims, payers may be concerned about the lift required to learn about the nuances of these types of services and claims. Luckily, with modern technology, the guesswork is removed. The only requirement from payers is the need to be curious and strive to get ahead of these claims, rather than waiting to see if they come in. It’s not an if, it’s a when.
Payers must move from reactive oversight to proactive foresight. That means:
- Leveraging AI-powered tools to detect contextual anomalies across behavioral health claims
- Building behavioral health-specific rulesets that align with clinical norms and emerging trends
- Applying real-time analytics to surface suspicious claims without disrupting care
- Achieving population-wide visibility to identify patterns before they escalate
Behavioral health is a strategic focus and forward-thinking payers are aligning their PI operations accordingly.
You Don’t Have to Do it Alone
While this may seem overwhelming, it’s not all on your shoulders. We’re also not suggesting you only rely on AI for something as critical and delicate as behavioral health. To address behavioral health claims with modern solutions, payers need partners—internal or external—who bring deep clinical, coding, and operational knowledge.
When you involve not only technology and artificial intelligence, but people with expertise in the field who understand the care pathways, who can distinguish high-value care from low-value excess, and who know how to turn data into action, true transformation happens.
At the intersection of intelligent systems and behavioral health expertise it’s not just better cost management and payment integrity—it’s about better care.
Better Processes, Healthier Outcomes
Let’s be clear: transformational behavioral health payment integrity programs should focus on cutting what doesn’t work. They should be designed to catch low-value, unnecessary, or suspect services so that members can access what actually helps them heal. Prioritize sustainability and savings will follow.
When payers modernize their behavioral health claims review processes, they’re investing in both fiscal responsibility and member health. Because behavioral health is health, managing it with care, precision, and foresight is how we build a smarter system for everyone.
To learn more about how Machinify supports intelligent behavioral health and substance use disorder reviews, contact us.
