Behavioral health billing: The risks behind modifier inconsistencies

Counsel to a behavioral health provider network reached out to CRA’s Forensic Services Practice after potential areas of noncompliance surfaced during a routine internal review. Our team conducted forensic analysis that revealed inconsistently-applied billing modifiers across providers, settings, and services. While the claims had often passed internal checks, they generated a combination of underpayments and overpayments, causing regulatory exposure and creating reputational risk. The team quantified the exposure and recommended coding protocol refinements and targeted staff training to prevent future issues.