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Commercial plans pay master's-level BH care less than public plans
A Massachusetts Health Policy Commission brief now gives you a citable number for your next payer conversation. Commercial psychotherapy rates grew more slowly than inflation from 2019 to 2023, and private plans reimburse Master's-level clinicians below what publicly funded plans pay. The Association for Behavioral Healthcare summarized the findings (https://www.instagram.com/reel/DdTqTrlEe3F/) in a reel posted today, but the underlying brief is the kind of third-party data t
Records reveal problems in Medicare's AI prior-auth experiment
The Electronic Frontier Foundation released about 1,000 pages (https://www.eff.org/deeplinks/2026/09/new-records-reveal-problems-medicares-ai-prior-authorization-experiment) of CMS records from its FOIA lawsuit over WISeR. WISeR is the AI-driven prior-auth model Medicare launched in January across six states. The files show vendors get paid to deny requests, with low quality scores trimming pay by only 5 to 10 percent. Two vendors logged more than 20,000 denials in three mont
Delaware ends prior authorization for behavioral health
Delaware's governor signed the Fair Standards Mental Health Act on September 8, scrapping prior authorization for behavioral health coverage in commercial plans, per Open Minds (https://openminds.com/market-intelligence/resources/090826desb22engrossed/). Emergency, crisis, and stabilization services get guaranteed coverage too, and the whole package reaches private policies issued or renewed after December 31, 2027.
CalmiGo selected for CMS ACCESS behavioral health program
Medicare opened a lane where technology companies bill it directly for behavioral health care, with new codes leaving eligible patients little or no out-of-pocket cost. CalmiGo, whose breathing-exhaler device and companion app treat anxiety, PTSD, and panic attacks, announced today (https://www.businesswire.com/news/home/20260915606147/en/CalmiGo-Selected-for-CMSs-ACCESS-Program-to-Provide-Technology-Supported-Chronic-Care-for-Behavioral-Health-Conditions) that it was selecte
CMS pushes tighter prior auth for Medicaid ABA therapy
Medicaid spending on ABA hit about $10 billion in 2025, up from $2 billion in 2021, which is why CMS is tightening oversight. Its toolkit (https://www.crowell.com/en/insights/client-alerts/cms-offers-guidance-as-scrutiny-rises-over-aba-therapy-in-medicaid) steers plans toward prior authorization, concurrent review and reauthorization tied to codes 97151 through 97158, with independent ASD diagnosis and closer review of high-intensity requests.
ACCESS adds 2027 tracks, behavioral track pays $180 a patient
The dollar amounts are out (https://www.hfma.org/payment-reimbursement-and-managed-care/cms-access-model-expansion/): CMS will pay tech vendors roughly $180 per patient for the ACCESS behavioral track, with half withheld until outcomes are reconciled after 12 months. The expansion adds heart failure, COPD, substance use, and tobacco cessation tracks starting April 1, 2027, plus a follow-on track for chronic musculoskeletal pain. Referring providers get a $30-per-service co-ma
CMS adds substance use, heart failure to ACCESS model
Starting spring 2027, participating organizations get paid for hitting measurable health improvements (https://www.cms.gov/newsroom/press-releases/cms-adds-medicare-options-help-people-manage-substance-use-disorder-heart-failure-other-common) in four new areas: heart failure, COPD, substance use disorders and nicotine dependence. The SUD track covers opioids, alcohol and other substances, with support for co-occurring depression and anxiety. Current analysis (https://www.onhe
62 of 254 payers publish their full prior-auth rules
Ask for the rule behind a prior-auth denial and most payers cannot show it. A review of 254 plans found 73 publishing no criteria at all.
Is Your Group Practice’s Billing System Sucking the Fun Out of Being an Entrepreneur?
You started your private practice for autonomy, flexibility, and to make a genuine clinical impact. You didn't start it to spend your Sunday evenings wrestling with clearinghouse rejections, deciphering cryptic Explanation of Benefits (EOBs), or answering frantic team texts at 9 PM. When administrative drag turns your dream business into a relentless grind, it’s a clear sign that demand has exceeded your resources. Let’s be honest: no one goes to graduate school to learn how
The 53-Minute Cap is Broken: Is Value-Based Care the Fix?
TRICARE goes AWOL, prior authorization requests multiply, and healthcare reimbursement remains stubbornly stuck in 1995. If you are running an EMDR intensive, offering Ketamine-Assisted Psychotherapy (KAP), or integrating somatic modalities into your practice, you already know the operational math does not add up. A full dosing and integration session easily takes two to four hours. Yet standard commercial insurance caps providers at a 53-minute 90837 code and tells you to ru
