Naz Andekian, Author at Analytic Healthcare Solutions

Your clinical director just got off a seven-minute peer-to-peer for a residential client. The reviewing MD didn’t read the chart, asked two questions, and downgraded the authorization to PHP anyway. That’s a week of revenue gone, and the written appeal is due in five business days.

This is the grind behind utilization review denial appeals — and most of it is winnable if your process is built for it.

TL;DR: What makes UR appeals win

Speak the criteria, not the narrative. Reviewers score against ASAM or MCG — your argument has to map to those dimensions directly.
Prep the peer-to-peer like a deposition. One page, six bullet points, the exact clinical markers that failed the lower level of care.
Written appeals win on specifics. Vitals, quotes, UDS results, failed outpatient history — not adjectives.
Track every denial reason by payer. Patterns repeat, and the second appeal is easier when you’ve seen the first.

Why do peer-to-peer reviews feel rigged before the call starts?

Because they kind of are. The payer’s medical director has a queue of 15 cases, a rubric in front of them, and about six minutes per call. They’re not reading your progress notes live. They’re listening for specific words that map to medical necessity criteria — and if your clinician walks in telling a story instead of hitting those words, the call is over before it starts.

The fix isn’t a better storyteller. It’s a pre-call sheet. Before every peer-to-peer, the UR team should hand the clinician a half-page document with:

The exact denial reason quoted from the payer letter
The ASAM dimension(s) that justify the level of care being requested (Dimension 3 for emotional/behavioral, Dimension 5 for relapse risk, etc.)
Three to five concrete clinical markers from the last 48 hours — CIWA scores, PHQ-9, SI documentation, failed step-downs, positive UDS, medication non-compliance
The failed-at-lower-level-of-care history, if it exists
A one-sentence summary of why discharge or downgrade is unsafe right now

Clinicians who walk into the call with that sheet convert peer-to-peers at meaningfully higher rates than those winging it from memory. That’s an industry observation, not a controlled study — but anyone running a busy UR desk will tell you the same thing.

What should a written UR appeal actually include?

Written appeals lose when they read like a treatment summary. They win when they read like a legal brief. Structure matters more than length.

1. Quote the denial reason verbatim

Open by citing the payer’s exact language and the date of the determination. This forces the reviewer on the other end to engage with the specific reason, not a general reassessment.

2. Cite the criteria set being applied

If the payer uses ASAM, reference the dimension. If they use MCG or InterQual, cite the specific guideline number. This signals that your appeal is scored against the same rubric they’re using.

3. Deliver the clinical evidence in bullets, not paragraphs

Reviewers skim. A wall of prose gets a wall of prose in return — denial upheld. Bullets with dates, scores, and direct chart quotes force the reviewer to either rebut each point or concede.

4. Address the downgrade alternative directly

If the denial offers a lower level of care, explain specifically why that setting cannot safely manage this patient right now. “Outpatient is insufficient because…” — then three reasons tied to documented behavior.

5. Attach the right pages, not the whole chart

Cherry-pick the two or three progress notes, the admission H&P, and any relevant labs. A 40-page attachment gets less attention than a 6-page one.

How do you prevent UR denials before they happen?

The best appeal is the one you don’t have to file. Three upstream fixes catch most problems before a denial letter goes out:

Concurrent review timing. Submit the next authorization request 48–72 hours before the current auth expires, not the day of. Late submissions get pended, and pended cases get denied.
Documentation templates tied to criteria. If your progress note template prompts clinicians to document across all six ASAM dimensions daily, your UR nurse has the ammunition they need without hunting.
Denial pattern tracking by payer. When you can see that one commercial payer consistently denies residential on Dimension 5 after day 14, you adjust documentation on day 10 — not after the denial.

This is where an in-house utilization review function that also owns billing matters. When the same team sees the denial, writes the appeal, and watches the cash hit (or not), the feedback loop is tight. When UR is one vendor and billing is another, the lessons don’t cross the gap. Global AHS runs the full RCM stack under one roof — UR, billing, VOB, appeals, credentialing — so a denial trend on Tuesday becomes a documentation change on Wednesday.

When should you escalate to an external review?

After two internal appeals fail, most commercial plans allow an Independent Review Organization (IRO) review. Escalate when:

The dollar amount justifies the clinical time — typically several thousand dollars or more per episode
You have strong documentation and the denial rationale is weak or internally inconsistent
The payer has a pattern of overturning at IRO for this diagnosis or level of care

IROs overturn a meaningful share of behavioral health denials because the reviewing physicians are usually contracted specialists, not the payer’s in-house staff. Don’t leave this option on the table for high-dollar cases.

Which UR denial reasons are hardest to overturn?

Three show up consistently and each requires a different strategy:

“Lack of medical necessity for continued stay.” Win with day-over-day functional decline data or new clinical events — not “patient is still working on their issues.”
“Member could be treated at a lower level of care.” Win with documented failed step-down attempts, environmental instability, or acute safety concerns.
“Services not covered under the plan.” This is a benefits issue, not a clinical one. The appeal goes to the benefits administrator with plan language, not to a medical reviewer.

Knowing which category a denial falls into decides who writes the appeal and what evidence goes in it. A clinical appeal on a benefits denial is a wasted appeal.

Next step

If your overturn rate is under 40% or your peer-to-peers feel like coin flips, the fix is usually upstream of the appeal itself. Global AHS offers a free 6-month billing and UR audit that quantifies where denials are coming from and what’s winnable. Request the audit here.

Frequently Asked Questions

How long do I have to file a UR denial appeal?

Timelines vary by payer and plan type, but most commercial plans allow 60–180 days for an internal appeal and require expedited appeals (for active admissions) to be filed within 24–72 hours of the denial. Medicaid MCOs and Medicare Advantage have their own timelines. Read the denial letter — the deadline is always stated there, and missing it forfeits the appeal.

Should the attending physician or the UR nurse do the peer-to-peer?

The attending or a physician familiar with the case should do it whenever possible. Payer medical directors give more weight to peer physicians, and clinical nuances land better MD-to-MD. UR nurses should prep the call, not run it, unless plan rules require otherwise.

Can I appeal a denial after the patient has already discharged?

Yes. Post-service appeals are standard and have their own timelines (often 180 days or longer for commercial plans). The clinical argument is the same — the documentation just has to support medical necessity as of the dates of service in question.

What’s the difference between a reconsideration and a formal appeal?

A reconsideration is typically an informal re-review by the same payer, sometimes without a new peer-to-peer, and doesn’t always count against your formal appeal levels. A formal appeal triggers the plan’s defined appeal process. Know which one you’re filing — it affects your remaining options if it fails.

What’s a normal UR denial rate for a behavioral health facility?

It varies heavily by payer mix, level of care, and documentation quality. As an industry observation, facilities with strong concurrent review processes run lower denial rates than those submitting authorizations reactively. The bigger question isn’t the raw denial rate — it’s your overturn rate on appeal. Overturn rates below 40% usually indicate a documentation or process problem, not bad luck.

Not sure where your billing is leaking?

Global AHS will audit your last 6 months of billing for free. We pull denials, aged AR, timely filing misses, undercoded services, and underpaid claims, then hand you a written report showing the exact gaps and what they’re costing you. No commitment, no sales pressure — just your numbers, laid bare.

Request your free 6-month audit →

Your 90837 hits the clearinghouse at $250. Two weeks later the EOB lands at $68 — a MultiPlan or Viant “repriced” amount the payer treats as payment in full. No contract, no signature, no agreement from you. Just a take-it-or-leave-it number and a member you can’t balance bill without blowing up the admissions relationship.

This is the out-of-network repricing squeeze, and if you run a behavioral health or SUD facility, it’s quietly eroding 20–40% of your expected OON revenue. The good news: repriced offers are offers, not adjudications. You can push back. The question is when it’s worth the effort.

TL;DR

Repriced offers from third-party networks (MultiPlan/Viant/Zelis/Data iSight) are negotiable — signing the single-case agreement is optional.
Accept quickly when the offer is at or above your usual contracted rate, cash flow is tight, or the member has high deductible exposure you’d rather not collect on.
Challenge when the offer falls below your cost-of-care floor, the methodology is unclear, or the payer has a documented history of paying higher on similar CPT/level-of-care combinations.
Document your cost basis, UCR benchmarks, and prior payment history before the call — repricers negotiate on data, not outrage.

Why does claim repricing hit behavioral health harder than other specialties?

When a patient has OON benefits, the payer often routes the claim to a third-party repricing network — MultiPlan, Viant, Zelis, Data iSight, and similar — that offers the provider a “negotiated” rate lower than billed charges but higher than the payer’s default OON allowable. The repricer takes a percentage of the savings. The payer treats the repriced amount as payment in full and zeroes out member balance-billing exposure.

Behavioral health gets hit harder than most specialties for three reasons. First, OON utilization is high — networks are thin, especially for residential and PHP. Second, billed charges for RTC, PHP, and IOP vary wildly facility to facility, which gives repricers a wide range to anchor low. Third, parity enforcement on OON reimbursement methodology is inconsistent, so repricers can lean on outdated UCR data without much pushback.

The result: a $1,200/day PHP claim gets repriced to $380. A $90791 intake at $450 gets offered $185. If you sign, that’s the ceiling.

When should you just accept the repriced offer?

Not every claim is worth a negotiation call. Accept the offer when:

The offer meets or beats your in-network equivalent. If your BCBS contracted rate for H0015 is $320/day and the repricer offers $340, take it and move on.
The member has a $7,500 OON deductible you’d otherwise chase. A signed single-case agreement often means the payer pays at in-network benefits — your net is higher than billing the patient for a deductible you’ll collect 30 cents on the dollar on.
The claim is older than 90 days and AR is aging. Cash today beats a slightly better number in 60 days, especially if the alternative is an appeal cycle.
The CPT code is low-dollar and high-volume. Individual therapy sessions aren’t worth a 45-minute negotiation call each. Batch them or accept the standard offer.

When is it worth challenging the repricer?

Push back when at least one of these is true:

The offer is below your documented cost of care. If your all-in per diem cost for residential is $540 and the offer is $410, signing locks in a loss.
The payer has paid higher on identical claims in the last 12 months. Repricers anchor low by default. If you have EOBs showing the same payer paid $620/day last quarter, you have leverage.
The methodology is opaque. If the offer letter cites “usual and customary” with no percentile or data source, ask. FAIR Health benchmarks at the 80th percentile typically run 2–3x Medicare for behavioral health services — far above most repriced offers.
It’s a high-dollar authorization-heavy episode. A 30-day RTC stay with solid UR documentation is worth fighting for. The repricer knows it too.

How do you negotiate a higher reimbursement with MultiPlan or Viant?

Repricers run phone-based negotiation desks. The reps have authority bands — they can typically move 10–25% from the initial offer without escalation, more with a supervisor. Here’s the approach that works:

1. Come with three numbers, not one

Have your billed charge, your walk-away floor (cost plus margin), and your target. Anchor at billed charges, land at target, never go below floor. If they won’t move above your floor, hang up and appeal the underpayment through the payer directly.

2. Cite comparable paid claims

“On claim [ID] for the same CPT and diagnosis family, this payer paid $X on [date].” This is the single most effective lever. Repricers have access to their own historical data — they know when you’re right.

3. Reference benchmarks, not emotion

FAIR Health percentiles, Medicare multiples, and state parity guidance carry weight. “This is below 150% of Medicare for H0015” lands harder than “this is unfair.”

4. Get the SCA language right before signing

Make sure the single-case agreement covers the full date range, all CPT codes on the claim, and specifies the payer will process at in-network benefits with no member balance beyond standard cost-share. Missing language here is where “accepted” offers still result in underpayments.

What do you do when the repricer won’t budge?

If the repricer won’t move above your floor, decline the offer in writing and let the claim adjudicate at the payer’s default OON allowable. Then:

Appeal the underpayment citing plan documents, parity (if commercial), and UCR benchmarks.
If the member has OON benefits, bill the patient responsibility per the EOB — but coordinate with admissions so it doesn’t become a surprise.
Track the payer and repricer pattern. Repeated lowballing on a specific payer is grounds for a contracting conversation. Sometimes the answer is to go in-network at a rate you’d actually accept — our contracting team runs these analyses regularly.

The operators who win at repricing aren’t the ones who fight every claim — they’re the ones with clean data on what each payer has paid historically, a defensible cost floor, and a workflow that flags underpayments within days, not months. Repricing patterns by payer look very different in SUD and mental health than they do in orthopedics, which is why we built behavioral health billing as a specialty practice rather than a generalist service. If you’re not sure what you’re leaving on the table, our free 6-month billing audit quantifies the repricing gap before you commit to anything — start here.

Frequently Asked Questions

Is a repriced offer from MultiPlan or Viant legally binding if I don’t sign?

No. Repriced offers are proposals for a single-case agreement. Without your signature, the payer must adjudicate the claim at the plan’s default OON allowable per the member’s benefits. You retain the right to appeal and, depending on state law and the member’s plan, to balance bill.

How much can I typically negotiate above the initial repriced offer?

Industry observation: first-line negotiators usually have authority to move 10–25% from the opening offer. Supervisor escalations can yield more, especially on high-dollar residential or PHP claims with strong clinical documentation and comparable paid-claim data to cite.

Does accepting a repriced offer waive my right to appeal?

Usually yes, for that specific claim. A signed single-case agreement typically includes language accepting the amount as payment in full. Read the SCA carefully — some include broader waivers that affect future claims or member balance billing rights.

Should I pursue the patient for the balance if I decline the repriced offer?

Only if the member has OON benefits and your admissions process disclosed OON financial responsibility clearly. Balance billing without upfront disclosure damages referral relationships and, under the No Surprises Act, can expose you to penalties depending on the service setting and notice requirements.

How quickly do I need to respond to a repricing offer?

Most offers include a 5–10 business day response window. Missing the window usually means the claim adjudicates at the default OON rate, which is often lower than the repriced offer. Build a workflow that flags repricing letters within 48 hours of receipt.

Are there CPT codes where repricing offers are consistently worse than default OON allowables?

Yes. H0015 (IOP), H0035 (PHP), and H2036 (RTC) per diems vary widely by repricer and payer. Compare the offer to the payer’s published OON methodology before signing — occasionally the default allowable at a FAIR Health percentile is higher than what the repricer proposed.

Not sure where your billing is leaking?

Request your free 6-month audit →

You pull the aging report Monday morning and a third of your AR is over 90 days. Your billing company blames “payer delays.” But admissions is sending clean intakes, census is steady, and the same claims keep showing up in the 120+ bucket month after month. The payers aren’t the problem. Your vendor is.

When cash flow slides at a behavioral health facility, operators blame payers first. Sometimes that’s right. More often, the billing vendor is missing the basics — and the symptoms are specific enough that an operator can diagnose the problem in an afternoon.

TL;DR: How to spot a failing billing vendor

AR over 90 days climbing past 20–25% is almost never a payer problem — it’s a follow-up problem.
First-pass denial rates above 10% on core SUD and mental health codes point to front-end gaps in VOB, auth, or coding.
Vague reporting — “we’re working on it” without claim-level detail — means no one is tracking the work.
Slow or templated communication from your billing contact is the leading indicator of everything else on this list.

What should behavioral health AR aging actually look like?

A healthy behavioral health AR distribution skews heavily into the 0–30 day bucket. As an industry observation, well-run SUD and mental health billing operations keep AR over 90 days in the 15–20% range, with total days in AR under 45. Commercial payers for residential and PHP/IOP services pay slower than primary care — but not unboundedly slower.

Warning signs in your aging report:

The over-90 bucket is growing month over month, not shrinking.
Large dollar amounts sitting in 120+ with no appeal activity logged.
Claims in “submitted” status for 30+ days with no payer acknowledgment — usually meaning they were never actually submitted, or were rejected at the clearinghouse and ignored.
The same claims appear in the aging report three months in a row with no status change.

Pull a claim-level aging report — not a summary. If your vendor can’t produce one within 24 hours, that itself is a red flag.

What denial rate is acceptable for SUD and mental health billing?

First-pass denial rates in behavioral health run higher than other specialties because of utilization review, level-of-care disputes, and auth complexity. Even so, a first-pass denial rate above 10% on core services — 90837, 90834, H0015, H0018, H2036 — usually means preventable errors are slipping through. Above 15%, you have a systemic problem.

Look at the denial reason codes. The ones that point directly to vendor underperformance:

CO-197 (auth missing/invalid) — a VOB and UR handoff failure.
CO-16 (claim/service lacks information) — sloppy claim scrubbing.
CO-45 or CO-97 recurring on the same CPT codes — nobody is correcting the fee schedule or bundling logic.
Timely filing denials — these should almost never happen. If you’re seeing them, claims are sitting in someone’s queue.

Denials are recoverable if they’re worked fast. The problem isn’t that denials happen — it’s that they’re not appealed inside the payer’s window. Ask your vendor for their appeal overturn rate. If they don’t track it, they’re not working appeals with any rigor.

Why is my billing company so hard to reach?

Communication is the leading indicator. Every operator who switches to Global AHS after a bad vendor relationship tells the same story: it started with slower email replies, then a ticketing portal replaced the phone, then the assigned contact turned over and the new person didn’t know the facility.

Specific red flags:

Your dedicated contact has changed twice in six months.
Questions about specific claims take 48+ hours to answer.
Reports come monthly instead of weekly, and they’re PDFs instead of exports you can filter.
You’re routed through a support queue instead of a person who knows your facility’s payer mix.

Behavioral health billing isn’t a ticketing problem. It’s a relationships-with-payers problem, and those relationships don’t form when the person on your account rotates every quarter.

What reporting should a billing vendor actually provide?

If your monthly report is a one-page summary of charges, payments, and adjustments, you’re flying blind. At minimum, you should have ongoing access to:

Claim-level AR aging by payer.
Denial log with reason code, date received, action taken, and current status.
First-pass clean claim rate and first-pass denial rate, broken out by payer.
Days in AR trended over the last 6–12 months.
UR approvals vs. denials by level of care.
Appeal pipeline — what’s pending, what’s overturned, what’s lost.

A vendor that can’t show you these numbers on demand doesn’t have them. And if they don’t have them, they’re not managing to them.

How do front-end gaps show up in back-end performance?

A lot of what looks like billing underperformance is actually broken handoffs upstream. Weak verification of benefits leads to surprise out-of-network claims. Missed auth extensions from utilization review lead to mid-stay denials that no appeal will save. Lapsed credentialing leads to “provider not par” denials that sit in AR for months.

This is why fragmented vendor stacks — one company doing VOB, another doing UR, another doing billing — tend to underperform. Nothing gets caught early because no one owns the full chain. Consolidating the stack, or at least auditing the handoffs, fixes more denial problems than hiring a better coder ever will. Worth looking at alongside your billing workflow.

How do I verify my billing company is underperforming this week?

Three things to do before Friday:

Pull a claim-level aging report. Sort by age bucket and dollar amount. Identify the top 20 oldest claims and ask your vendor, claim by claim, what’s being done on each.
Run a denial audit on the last 90 days. Group by reason code. Anything that clusters around auth, eligibility, or coding is preventable.
Request an appeal log. Count how many denials from the last quarter were actually appealed. The gap between denied and appealed is usually where your cash is.

If those three exercises surface gaps — or if your vendor pushes back on producing the data — you have your answer. Global AHS runs a free 6-month billing audit for treatment centers that want the numbers quantified before making any decisions. Request the audit here.

Frequently Asked Questions

What percentage of AR over 90 days is considered a red flag?

As an industry observation, behavioral health facilities with well-run billing operations keep AR over 90 days in the 15–20% range. Consistently above 25%, or climbing month over month, usually points to follow-up and appeal work not being done — not to slow payers.

What is a reasonable first-pass denial rate for SUD and mental health claims?

Behavioral health runs higher than primary care due to UR and level-of-care complexity, but a first-pass denial rate above 10% on core CPT and HCPCS codes (90837, H0015, H0018, H2036, etc.) generally indicates preventable front-end errors. Above 15% is systemic.

How quickly should my billing company respond to claim-specific questions?

Same business day for urgent questions, within 24 hours for routine claim status inquiries. If you’re waiting 48+ hours or getting templated replies from a ticketing portal, that’s a leading indicator of deeper performance issues.

What reports should I be getting from my billing vendor?

At minimum: claim-level AR aging by payer, a denial log with reason codes and current status, first-pass clean claim rate, days in AR trended over time, UR outcomes by level of care, and an active appeal pipeline. You should be able to pull these on demand, not wait for a monthly PDF.

Can switching billing companies mid-year cause cash flow disruption?

There’s always a transition period, but a structured handoff — running parallel for 30–60 days, transferring aging claims with documented status, and re-credentialing cleanly — typically stabilizes collections within one billing cycle. The bigger risk is staying with an underperforming vendor and watching AR age out past timely filing windows.

Not sure where your billing is leaking?

Request your free 6-month audit →

Your aging report is climbing past 90 days. Claims you submitted in March still haven’t been touched. Your current biller stopped returning calls two weeks ago, and the last UR got approved because your clinical director worked it on a Saturday when no one at the billing company picked up. You’ve already decided you need to switch. The question is how to do it without torching six figures in open AR.

Switching behavioral health billing companies is one of the higher-risk operational moves a treatment center can make. Get it wrong and claims get lost in transit, timely filing windows close, and cash drops for a quarter. Get it right and you recover revenue you didn’t know was stuck.

Here’s the checklist operators use to make the move, plus the questions that separate a real RCM partner from a login and a prayer.

How do you know it’s time to switch billing companies?

Not every billing problem is a biller problem. Before interviewing replacements, rule out the usual suspects on your side: intake collecting bad insurance info, clinical documentation missing medical necessity language, or UR deadlines getting blown because no one owns the calendar.

That said, the following patterns are hard to blame on anything but the vendor:

Days in AR creeping past 60 with no explanation and no action plan.
Denials sitting unworked past the appeal window — especially 90837 downcodes and medical necessity denials on residential and PHP claims.
You can’t get a clean, current aging report on demand.
Your dedicated account rep has changed three times in a year, or you no longer have one.
UR approvals are coming in late, short, or not at all, and your census is taking the hit.
Payer credentialing gaps are being discovered by your billers, not prevented.

Three or more of those, and the math almost always favors switching.

TL;DR: What does a clean billing company transition look like?

Don’t terminate first. Sign with the new biller, build the transition plan, then give notice — in that order.
Protect the open AR. Decide in writing who works claims with dates of service before the cutover. That single clause saves the most revenue.
Export everything before access is revoked. Aging, payer contracts, fee schedules, EOBs, ERA enrollments, patient ledgers, clearinghouse history.
Re-point ERAs and EFTs early. Payer portal updates take 30–45 days. Start day one, not cutover day.
Interview on specifics, not pitches. Ask about 90837 denial rates, UR turnaround, and how they handle timely filing on inherited claims.

What should you do before giving notice to your current biller?

The worst transitions happen when an operator fires the old company in frustration on a Friday and starts looking for a new one on Monday. By then, logins get shut off, AR goes cold, and claims past timely filing start dying quietly.

Before you send a termination letter, lock these down:

1. Read your current contract

Look specifically for the termination clause, notice period (usually 30–90 days), data return obligations, and any fees for claims worked after termination. Some contracts entitle the outgoing biller to a percentage of collections on claims they submitted, even if your new biller does the follow-up work. Know that number before you negotiate with anyone.

2. Pull a full data export now

Don’t wait until the relationship is tense. Request:

Current AR aging by payer and by date of service
A list of every claim submitted in the last 12 months with status
All EOBs and ERAs
Patient demographic and insurance files
Your payer contract copies and fee schedules
Clearinghouse enrollment records
Credentialing files and CAQH attestation history

Industry observation: the data you can get while the relationship is cordial is often five times what you’ll extract after you give notice.

3. Map your payer mix and open authorizations

Every active patient has an authorization with a start date, end date, and level of care. If that spreadsheet doesn’t already live in your EMR, build it before cutover. Dropped auths during transition are where census revenue leaks.

What questions should you ask a new behavioral health billing company?

Every RCM vendor’s sales deck says the same three things: experienced team, technology-driven, dedicated support. None of that is diligence. Ask questions that force specifics.

On billing performance

What’s your average days in AR for residential, PHP, and IOP clients?
How do you handle 90837 downcodes to 90834? What’s your appeal success rate?
Walk me through your denial workflow. Who touches a denial on day one, and what’s the turnaround to appeal?
How do you handle single case agreements and out-of-network negotiations?

On utilization review

Do you do concurrent UR in-house, or subcontract it?
What’s your average turnaround from clinical handoff to payer submission?
How do you handle peer-to-peers? Does your UR team coordinate them or does that fall back on my medical director?

If the answer to UR questions is vague, that’s a real warning sign. A strong utilization review process is the difference between a full census and a discharge-heavy month.

On the transition itself

Who works the open AR from the previous biller, and how is that scoped?
What’s your onboarding timeline — when does the first clean claim go out under you?
How do you handle claims that were denied before you took over but are still within appeal window?
What reporting will I get in the first 30, 60, and 90 days?

On people and accountability

Who is my named point of contact and what’s their direct line?
How many accounts does that person carry?
What happens when they’re out — who picks up?

A real answer sounds like “Maria is your account manager, she carries 8 facilities, her backup is Jon, here are both their cells.” A bad answer is “you’ll have access to our support team.”

How do you protect open AR during a billing transition?

This is where most money is lost, and most of it is preventable with one well-written paragraph in your transition plan.

Decide — in writing, signed by both billers if possible — who owns claims by date of service. The cleanest split looks like this:

Outgoing biller continues to work claims with dates of service before the cutover date for 60–90 days, on a reduced percentage or flat fee.
New biller owns everything from the cutover date forward, plus any claim the outgoing biller has not touched in 30 days.
Appeals on pre-cutover denials go to whichever party has the bandwidth and documentation, agreed case by case.

If the outgoing relationship is too far gone for that arrangement, plan for the new biller to inherit everything and price it accordingly. Expect a temporary dip in collections in months two and three — that’s normal, not a red flag, as long as the aging report starts compressing by month four.

What does the first 90 days with a new biller actually look like?

A realistic timeline for a mid-sized residential and PHP operation:

Days 1–15

Data migration. EMR integration or file feeds established. Payer portal access transferred or new logins created. ERA and EFT re-enrollment submitted to every payer — this alone is a 30–45 day process with some Medicaid MCOs, so starting day one matters. Credentialing and payer enrollment gaps get identified and flagged.

Days 16–45

First clean claims go out under the new biller. Initial aging cleanup on inherited AR begins. You should be getting weekly reports by week three, not monthly. Any authorization gaps from the transition are closed.

Days 46–90

Denial rates stabilize, AR days start trending down on post-cutover claims, and recovery on aged AR shows up in cash. If by day 90 your new biller can’t show you a side-by-side of inherited aging vs. current aging, that’s a conversation to have immediately.

What are the most common billing transition mistakes?

Giving notice before signing a new contract. Now you’re negotiating from weakness with every vendor who finds out.
Assuming the old biller will hand over data cleanly. They might. Don’t bet AR on it.
Not updating ERAs and EFTs fast enough. Payments keep flowing to the old biller’s bank account or clearinghouse, and clawing them back is painful.
Letting authorizations lapse during the handoff. The new UR team needs the active auth list on day one, not day fifteen.
Signing a long contract with the new biller to get a discount. A 90-day out clause is worth more than a 10% rate cut.

Next step

If you’re evaluating a switch and want a straight answer on what your transition would look like — including how the open AR gets handled and what the first 90 days should produce — schedule a 20-minute call. No deck, no pressure. Just the specifics.

Frequently Asked Questions

How long does it take to switch behavioral health billing companies?

Plan on 60–90 days from signing with a new biller to a fully stable state. The first clean claims usually go out within the first 2–3 weeks, but ERA and EFT re-enrollments with payers often take 30–45 days, and inherited AR cleanup runs through the first 90 days.

Who works my open AR when I switch billers?

That should be decided in writing before you give notice. The cleanest arrangement is the outgoing biller continues working pre-cutover claims for 60–90 days while the new biller handles everything from the cutover date forward. If the outgoing relationship is too strained, the new biller inherits all AR and prices accordingly.

What data do I need to export from my current billing company?

At minimum: current AR aging by payer, 12 months of claim history with statuses, all EOBs and ERAs, patient demographic and insurance files, payer contracts and fee schedules, clearinghouse enrollment records, and credentialing and CAQH files. Pull this while the relationship is still cordial.

Will my collections drop during the transition?

Usually yes, temporarily — most commonly in months two and three as old claims age out and new claims are still moving through first-payer cycles. A competent new biller should show aging compression and improving collections by month four.

Should I give notice to my current biller before signing a new one?

No. Sign the new contract, build the transition plan, then give notice. Terminating first leaves you negotiating from weakness and at risk of losing access to data and portals before you’re ready.

What’s the single most important question to ask a new behavioral health biller?

Ask them to walk through their denial workflow in specifics — who touches a denial on day one, what the turnaround is to appeal, and what their success rate looks like on common behavioral health denials like 90837 downcodes and medical necessity denials on residential. Vague answers here predict vague performance.

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