Behavioral health has the highest denial rates, the most enforcement variance, and the clearest patterns. It's where we start.

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PHP Denial Rate

25–35%

2–3× general medical

IOP Denial Rate

20–30%

Intensive outpatient programs

SUD Treatment

15–25%

Substance use disorder

§ 01

Why behavioral health first

Highest denial rates

BH claims face denial rates 2–3× higher than general medical, representing millions in lost, recoverable revenue annually.

Enforcement varies

Same documentation gets different outcomes by payer — but 80.7% of appealed denials overturn, while only 11.5% are ever appealed.

Repeatable patterns

Medical necessity denials cluster around PHP, IOP, and SUD — where precedents scale fastest with clear ROI in 30–45 days.

§ 02

The problem is enforcement variance, not documentation

MCG and InterQual define requirements. But how payers enforce those requirements varies dramatically.

United requires standardized screening instruments like PHQ-9 and GAD-7.

Cigna explicitly requires functional impairment evidence (impact on daily living, occupational, or social functioning).

Aetna uses evidence-based clinical guidelines from nationally recognized sources.

All payers reference MCG/InterQual — but enforce them differently, on different timelines, with different undocumented thresholds.

46%

of orgs use AI for RCM

improvement in BH denial rates

10+

years BH rates have held

§ 03

What results look like

Sprint impact — illustrative example based on client engagement data.

Time-to-Packet

65%

faster — 195 min → 68 min

Knowledge Access

1 → All

Expert → entire team

Measurable ROI

30–45 d

to before/after improvement

New staff ramp faster

Precedents encode what used to take years to learn.

Experienced staff multiply

Their wins become reusable across the whole team.

Drift gets caught

When payers shift, your team flags it — not 6 months later.

§ 04

Common questions

Why does behavioral health have higher denial rates?+

BH medical necessity criteria are inherently more subjective. “Clinically appropriate” for PHP or IOP requires judgment calls about symptom severity, functional impairment, and treatment history — and those calls vary by payer and reviewer.

What denial types does Stratum focus on?+

We zero in on medical necessity disputes — the cases where payer interpretation varies most and human judgment tips the outcome.

What clinical criteria do you work with?+

All the major frameworks your team already knows: ASAM, MCG, and InterQual — captured at the enforcement level, not just the requirement level.

What’s the ROI timeline?+

Most partners see measurable improvement within 60–90 days.

See all FAQs →

§ CTA

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We’ll analyze 25–50 of your recent BH denials. Diagnostic and scoping-focused — no precedent mining until you’re ready.

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