This week, I received three emails from community behavioral health organizations that all said some version of the same thing:

“We feel stuck. We have no leverage. And we don’t know how long we can stay afloat like this.”

• All three organizations were placed on prepayment review.
• All three provide essential behavioral health services in their communities.
• All three described the same challenges: cash flow disruptions, no clear point of contact at the payer, and in one case serious concern about dipping into reserves just to stay operational.

Let me be clear from the start: I understand why prepayment reviews exist.
There are bad actors in healthcare. I’ll be the first to support it and I understand the value of program integrity programs.

But when oversight meant to protect the system begins to disrupt compliant behavioral health providers, we have to pause and ask a harder question:

So where does the fallout land when rules leave room for interpretation—and providers are left guessing where a payer stands?

You’ve heard me say this before, and it’s worth repeating behavioral health has some of the most complex rules in healthcare. Payers have significant autonomy to interpret them often without clearly communicating their position to providers.

The Part That Rarely Gets Explained

Patterns in utilization, diagnosis mix, frequency of services, or billing behavior can flag “risk” long before a human ever opens a chart. It’s called an algorithm.

Providers are often left responding to a process they don’t fully understand, with little explanation of what caused or how to fix it.

Behavioral health organizations don’t operate like large hospital systems. Many run on thin margins, rely heavily on Medicaid, and serve patients with complex needs that don’t fit neatly into automated models.

When prepayment review begins, the impact is immediate:

• Payments slow or stop depending
• Leadership shifts from patient care to cash-flow crisis management

What makes this especially difficult isn’t the review itself. More often, it’s the silence that follows even from carriers I’ve personally had good experiences with.

Providers describe uploading records into a black hole. Emails go unanswered. Phone calls lead nowhere. Weeks turn into months with no clear path forward.

What Providers Can Do?

While much of this conversation needs to happen at the payer level, providers are not completely powerless even when it feels that way.

Here are a few practical steps organizations can take once prepayment review begins:

1. Ask direct questions early and in writing.
   Providers should ask what triggered the review, what data points are being monitored, and what success looks like. Even limited answers are better than silence. Sometimes this involves several different communication methods.
2. Get your documentation house in order anyway.
   Strong, well-organized documentation often determines how smoothly and quickly a prepayment review moves once records are requested. Investing in proactive reviews from the beginning matters.
3. Centralize payer communication.
   One point of contact. One upload process. One internal tracker. Fragmented responses slow everything down.
4. Track the operational impact in real time.
   If prepayment review affects payroll, staffing, scheduling, or patient access, document the impact. This information matters during escalation and in more formal conversations if needed.
5. Push for an exit plan.
   Prepayment review should not be open-ended. Providers should be asking what benchmarks must be met to come off review and how progress is measured.

These steps won’t fix the system, but they can help organizations survive it.

A Message to Payers: Oversight Has Consequences

We need to be honest about what’s happening.

Algorithm-driven oversight places enormous power in payer hands while shifting the financial risk almost entirely onto providers often without warning, explanation, or a clear endpoint.

When a behavioral health organization is placed on prepayment review, cash flow slows or stops immediately, but the obligation to deliver care does not. Staff still need to be paid. Services must continue. Patients don’t disappear just because claims aren’t moving.

Extended prepayment review without communication, transparency, or timelines creates financial and operational risk while offering providers no clear path forward.

Often providers cannot identify a decision-maker, cannot get responses, and cannot understand what will bring the review to an end, the process stops being corrective and starts being punitive whether that is the intent or not.

If oversight efforts reduce access to care, the system has missed the mark.

Responsible oversight requires more than detection. It requires:

• Clear ownership and points of contact
• Transparency around what is being measured
• Defined timelines and exit criteria
• Real communication, not automated silence

These should be considered baseline expectations in a system that claims to support access to behavioral health care.

Why I’m Speaking up

I’ve worked across healthcare compliance, documentation, and billing, with much of my work focused on behavioral health. I’ve seen clear cases of fraud, and I’ve also seen committed organizations pushed to the brink while trying to do the right thing.

This is about making sure systems designed to protect patients don’t end up limiting access to care. And when payers say, “We support our providers,” those words need to be backed by action.