The Divide Between Providers and Health Plans Is Getting Too Wide

I am frustrated, and I think this deserves a conversation.

I work with behavioral health organizations that care deeply about their patients and want to do things correctly. I also see how hard it can be for those organizations to understand what health plans expect, get meaningful answers, and protect payment for the services they provide.

There is a tremendous divide between providers and health plans. Providers are expected to understand the requirements, deliver the care, document it correctly, and accept the financial consequences when something is missing in that documentation. But when they ask for clarification, getting a useful answer can be a challenge.

I have reached out to departments myself, trying to get answers that would help organizations address concerns proactively. I have not received the level of response or cooperation I believe these organizations deserve. Meanwhile, providers are left trying to figure out what will satisfy a future reviewer.

We need to do better than this.

Yes, providers have a responsibility here.

Anyone who knows me knows I will continue to preach about documentation for as long as I can. Good care needs to be supported by a record that explains what happened and why.

Tell the patient’s story. Explain the intervention, how it was used, and how the patient responded. Show the connection to the treatment plan, the patient’s progress or continued barriers, and the reason services are still needed. A reviewer cannot see everything you know about that patient unless you put it in the record.

Organizations also need to be proactively auditing. If you are not checking your providers’ work, you may not discover a documentation problem until an insurer attaches a repayment demand to it.

But accepting that responsibility does not mean we should stop questioning how health plans communicate requirements or respond to deficiencies.

When one missing detail puts the entire payment at risk as an example

Consider documentation of the clinician to client ratio in a group when a maximum number of clients per clinician applies. There is a meaningful difference between exceeding that limit and failing to clearly record the ratio in the progress note.

Both deserve attention. But they raise very different questions.

Was the service delivered outside the requirement? Or was the service delivered appropriately, with a documentation omission that needs to be evaluated alongside the available records?

I am seeing conscientious behavioral health organizations face repayment concerns over details like this. That is difficult to accept when the record otherwise supports the treatment, the level of care, and the work being done.

I am not asking anyone to ignore requirements. I am asking whether the response adequately considers what the deficiency actually tells us about the service.

Providers need answers they can use

“We cannot tell you how to code” does not answer a question about a health plan’s own payment or documentation requirements.

Providers should make coding decisions based on the services delivered and the applicable guidance. Health plans should be able to explain their policies, the criteria used in their reviews, and what documentation they expect to support payment.

Those are reasonable questions. Answering them should be part of the relationship.

But there is another very real problem: getting access to someone who actually understands the question and has the knowledge or authority to answer it. I have experienced this myself. When repeated attempts do not produce a meaningful response, it leaves providers feeling that no one on the other end cares whether they get it right, even though they will be held accountable if they get it wrong. That is a serious problem in a relationship that directly affects patient access and an organization’s ability to continue providing care.

The same concern applies to the use of data and AI in identifying services for review. A pattern can raise a question. It cannot, by itself, explain an organization’s patient population, services, staffing, or clinical circumstances. A concern identified at one organization should prompt questions about another, rather than an assumption that the same problem exists there.

Providers need a meaningful opportunity to explain those differences and have that information considered.

I think it is time for a collective conversation

I do not have every answer, but I believe behavioral health organizations need to come together and ask health plans for specific changes:

• Clear, accessible documentation and payment requirements, with notice when expectations change.
• A reliable path to someone who can answer policy questions.
• Review processes that distinguish between unsupported care, services delivered outside requirements, and documentation omissions.
• A meaningful opportunity to provide context and supporting records.
• Education that helps organizations correct recurring problems before those problems grow.

A coalition could bring actual examples, identify recurring barriers, and request a working conversation with health plans. The purpose would be to establish expectations both sides can understand and act on.

I support accountability. I support meaningful quality measures and reviews that examine whether care is necessary and whether patients are benefiting. Providers should be able to demonstrate the value of their work.

Health plans should also be willing to examine whether their own processes help providers meet expectations.

I will keep teaching documentation and helping organizations prepare for audits. But I also want to see a relationship in which asking how to get something right produces a useful answer.

Good providers are working hard to keep their doors open. We need to address this divide while they still can.