3 Things Self-Funded Employers Should Know About Behavioral Health Claims Management in 2026

Behavioral healthcare is more in demand than ever. After a pandemic-era rise in diagnoses of depression and anxiety, behavioral health claims have continued to climb. According to a 2024 report from FAIR Health, the percentage of patients who received medical services for mental health diagnoses increased nearly 40% from 2019 to 2023.

Covering claims for these treatments is crucial. Better behavioral health improves overall health conditions, workplace wellbeing, and long-term cost management. 

But in today’s market, individual costs and care plans vary widely—and they don’t always reflect the best available clinical evidence, economic norms, or regulatory standards. 

Self-funded employers deserve to know the claims they cover are priced and utilized effectively. In this article, we’ll cover three factors to consider when managing behavioral health claims, including how a skilled third-party administrator can help handle these vital tasks.

1. Variable Pricing and Utilization are Driving Costs Up

One of the struggles with behavioral health claims is cost. With demand for behavioral health services still on the rise, the healthcare industry is dealing with a shortage of mental health providers. That puts upward pressure on pricing, driving up the total cost of care.

But it’s not just service rates that are challenging—it’s how difficult pricing is to predict.

The cost of behavioral health services can vary widely, according to research from Health Affairs Scholar. One-third of private practice therapy providers don’t accept insurance, creating meaningful gaps between commercial reimbursement and self-pay rates. Medicaid rates, for example, are an average 40% lower than cash pay rates, which averaged $143.26 a session in 2024.

Behavioral health claims are also disproportionately represented in out-of-network spending. In these scenarios, billed charges can far exceed allowed amounts and providers may not be open to repricing or negotiation.

Finally, many behavioral health treatments don’t come with clear outcome measurement. In some cases, treatment frequency or duration can exceed clinical guidelines, continuing beyond documented health improvements.

Taken together, these variables make it difficult for health plan sponsors to anticipate costs and budget appropriately. They may find themselves paying for service charges that exceed prevailing market rates, covering services that continue without medical reassessment, or managing the greater fiduciary or compliance risk that comes with out-of-network services.

That’s a lot to account for, in both budget and claims management.

2. Cost Management Must Be Compliant with Federal Requirements

Given ongoing cost pressures, it’s no surprise that self-funded employers have looked for ways to manage their overall spend. But these cost management efforts need to comply with the framework of the Mental Health Parity and Addiction Equity Act (MHPAEA).

Under the MHPAEA, health plans must treat mental health and substance use benefits the same as medical and surgical care. That means they can’t apply stricter rules, higher barriers, or more limited coverage to behavioral health services.

Recent regulatory updates have made this even more clear. Health plans are now expected to show they:

• Document how care is reviewed and approved in a way that’s consistent across all forms of care.
• Provide comparable access to in-network providers.
• Use consistent methods for reimbursing claims across all benefit classes.

And although certain federal enforcement timelines have been paused or delayed, the underlying requirements haven’t gone away. Parity is still the law, and many states are enforcing it too.

For self-funded employers, this means that cost management measures need to prevent overuse or inconsistent billing without putting up barriers that only apply to behavioral health claims. When done well, it ensures behavioral health benefits are managed with the same fairness and attention to compliance as the rest of the health plan.

3. A Strong TPA Can Make a Big Difference

The complexities of behavioral healthcare can be difficult. A strong third party administrator (TPA) can play a critical role in managing these responsibilities. Your TPA should be both a cost steward and a compliance safeguard so that you can expect:

• In-network and out-of-network monitoring of behavioral health claims, including the identification of pricing outliers, anomalies in utilization, and any emerging trends.

• Provider negotiation and repricing expertise, which engages providers directly and uses defensible market-based repricing to make a big difference in the ultimate costs of out-of-network claims.

• Clinically aligned utilization review to ensure treatment is assessed at the appropriate level, intensity, and duration, and that accepted standards of care are being followed.

• Compliant plan design support to encourage in-network engagement, support early intervention, and coordinate care while remaining compliant with MHPAEA and other regulations.

• Data-driven reporting for both employers and brokers that breaks down behavioral health utilization, cost drivers, and outcomes.

At Healthgram, we emphasize each of these standards and more. With our partnership, employers are able to make informed decisions while helping their people access appropriate, cost-effective behavioral healthcare.

Next Steps for Self-Funded Employers 

No one doubts the importance of behavioral health treatment. But when it comes to claims management, pricing, utilization, and medical outcomes take extra time and attention for health plan sponsors to ensure budget and care standards are being met.

As behavioral health continues to shape employer health plan outcomes, partnering with a TPA like Healthgram brings structure, oversight, and regulatory awareness that can make a meaningful difference—and protect both members and plan sponsors over the long term.

Healthgram can help employers support access to behavioral healthcare while also managing this complex and evolving area of claims management. Learn how.