DATE: March 19, 2026 at 06:54PM
SOURCE: PsychBilling Coach Billing Blog by Susan Frager
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TITLE: Exhaustion and Systemic Accountability Failure

URL: https://psychbillingcoach.com/systemic-accountability-failure/

Battling insurance probably never was anyone’s idea of fun. But these days, we’re all exhausted from constant systemic accountability failures: insurance payers not taking responsibility for their mistakes.

The national companies are organizational monoliths grown from a sequence of mergers and acquisitions, with workflows now designed for their convenience, to retain as much profit as possible, and to disclaim responsibility. And with a few exceptions, even smaller plans seem to have followed suit. If it works for their larger, wealthier competitors, why not?

Most of the time, insurance companies are never held liable for their accountability failures. If companies do have to pay a regulatory fine here or there, most of the time it’s a small amount (to them!) that they probably regard as a routine cost of doing business. But none of that money ever gets passed to healthcare professionals as a form of compensation.

What will be the cost to us all, if clinicians are expected to carry on, year after year, conducting “business as usual,” under a system designed to ensure that as little money as possible is paid out for healthcare services?

Individual claims SNAFU’s

Every day, I consult with clinicians who come to me for help getting responses from systems which ignore them when they try to accomplish tasks the way they’re instructed to. For example…

Is it really necessary to write a letter to the CEO of a billion-dollar corporation in order to prove timely filing? Apparently it is, if the payer is Anthem BCBS and their sole inbound electronic gateway, Availity, has a systems issue.

Standard protocol is to send an appeal with proof of timely filing. On two occasions this year, one practice had incontrovertible clearinghouse proof of timely filing on days when Availity had publicly reported tech issues. It should be open and shut: complete the appeal form, and send it in with the proof of timely plus a copy of Availity’s issue report.

DENIED. “Not filed timely! The form letter showed no evidence anyone had looked at our attachments or even that a human being ever laid eyes on the appeal at all. No contact person listed.

(Did I mention that Anthem is part-owner of Availity?)

In another example, it was necessary to write to a CEO and the state’s insurance department before a health plan would agree that yes, an opted-out Medicare provider is forbidden *by law* to file claims to Medicare and that they owed a responsibility to their member to pay the secondary payer portion even without a Medicare remittance.

I continually work with clinicians to resolve:

• Credentialing and contracting that takes months and even when it’s supposedly “complete,” it’s not, and claims are denied or paid out of network.
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• Electronic enrollments that take months.
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• Single-case agreements that never quite coalesce between all the various departments for hassle-free claim payment.
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• Addresses and other important provider data that gets updated 5 different ways but two years later the insurance company still hasn’t made the changes despite hassling clinicians for updates every 90 days.
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• Insurance companies mysteriously not paying at the agreed-upon level of reimbursement. In some cases, even saying “sorry we put that in your contract, it was a mistake, but no, we won’t honor it.”
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• Unexplained rate decreases with no prior notice.
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• Clawbacks years after the fact because they couldn’t figure out Coordination of Benefits.
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• Clinicians trying to terminate their contracts (wonder why?!?) with no response.
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Would anything change, if executive teams were suddenly deluged with protests about their unworkable systems and accountability failures? I wonder. But if Round 1 ends in shenanigans, I find that kicking issues up to the executive level gets the job done!

Extreme examples of systemic accountability failure

Remember the 2022-2024 massive clawbacks from out of network LCSW’s accepting United Healthcare Medicare? United paid for 2 years at 100% of Medicare, when LCSW’s are supposed to receive 75%. No one could fight the clawbacks because Medicare fees are determined by the government. To knowingly retain a payment from federal healthcare funds that you aren’t entitled to is a serious offense called a reverse false claim.

It wasn’t the fact of the overpayment that was in dispute; what struck me was how United never experienced consequences for their accountability failure. Shouldn’t the federal government have been able to intervene? This wasn’t a small, localized issue affecting one or two people. It was a national accountability failure that was allowed to continue for a two-year period. Shouldn’t there have been some sort of penalty? Which, if there was any justice, could have been distributed among the clinicians affected by United’s negligence, since the fines would have come from United’s profits, not the Medicare trust fund.

Saying “Sorry for the inconvenience” on a form letter demanding a clawback just doesn’t cut it.

More recently, the TRICARE T-5 implementation beginning January 2025 was, and continues to be, a disaster even 15 months later. The extent of the systemic accountability failure was so extreme, it made the national news. There’s now a very active Facebook group for mental health clinicians struggling with TRICARE. Clinicians I worked with encountered some or all of these issues:

• Contracts not activated for months. When they were, they contained inaccurate information.
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• Claims taking months to begin to pay.
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• Then paying at the wrong reimbursement rate.
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• Paying out of network instead of in-network for months, resulting in unexpected clawbacks for thousands of dollars.
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• Applying an outdated standard that all counselors be required to have physician referrals and supervision.
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• EDI enrollments that took months to approve.
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What consequences have Humana and TriWest faced? I’m not aware of any, to date. According to a March 5, 2026 article on the American Physical Therapy Association page, Congress has asked for a report on the situation, due by March 31st. The report is to include issues of critical importance to the clinician community:

• Causes of TRICARE payment delays
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• Reasons clinicians have left TRICARE’s network
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• Average claim processing times
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But Congressional inquiries typically drag on and on. And even if Congress does eventually hold Humana and/or TriWest accountable, how does that help healthcare professionals who are suffering financial losses today? If there are fines, the money goes to the US Treasury. Not helpful for clinicians trying to operate a small private practice, pay bills, and earn enough to live.

Short of litigation, I know of no avenue for financial remediation to providers who are victims of systemic accountability failure. And who has the resources or energy for lawsuits?

Is it any wonder that mental health clinicians burn out, exhausted from the continual fighting? Staying out of network or leaving panels, if you can sustain an out of network practice, is an understandable choice.

Can we return to balance?

Clinicians can have money clawed back for failing to document start and stop times of a therapy session, but billion-dollar corporations bungle national contracts affecting millions of lives without meaningful consequences. Aside from the basic injustice, how long can the American healthcare workforce survive under these conditions? It’s unsustainable. The mental health advocacy group Inseparable just published a mental health workforce report, and the picture is grim. Their main findings:

• 42% of the US population (144 million people) lives in a mental health professional shortage area (HPSA).

• Is your location considered a HPSA? Find out here. You’d be surprised I’ve seen mental health HPSA’s in non-rural areas.
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• A majority of Americans do not receive treatment.

• About half of people experiencing mental health issues
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• 80+% of people with substance use disorders
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• In more than 30 states, mental health care is at least twice as likely to be out of network as treatment for medical conditions despite national and state parity laws.
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The situation is correctible, but only if the systems which reward accountability failures on the part of insurance companies are rebalanced.

URL: https://psychbillingcoach.com/systemic-accountability-failure/

Articles can be found by scrolling down the page at https://psychbillingcoach.com/billing-blog/ under the title "The Billing Blog".

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