Mark Loes — First Touch Email Comparison

Mark,

I've been tracking behavioral health denial patterns across the WA commercial market and something keeps showing up — the facilities with the longest operating history are often the ones leaving the most on the table. Not because they don't know denials are a problem, but because the appeal economics never made sense at scale.

A GAO finding last year confirmed what you've probably intuited: CMS isn't auditing MA prior auth denials in BH. Payers have the data advantage, and they're using it.

I started Stratum to close that gap — we build payer-specific denial precedent so that appeal assembly is fast enough to actually be worth doing. For a PHP/IOP operation like Sundown, the recoverable dollars tend to cluster in predictable places once you can see the pattern.

28 years at Sundown and your work on the WA DoH CDP Advisory Committee means you've watched this from more angles than most. I'd like to show you what we're finding and see if it matches what your team is experiencing.

Worth 15 minutes?

Patrick Lord
Founder, Stratum Collective

Mark,

Two data points that intersect at Sundown's doorstep:

First — GAO confirmed last year that CMS is not auditing Medicare Advantage prior auth denials in behavioral health. BH is the least-scrutinized denial category at the federal level. Payers know this and the denial behavior reflects it.

Second — across WA facilities running residential, PHP, and IOP, we're seeing commercial payer denial clusters that follow repeatable patterns. The overturn rate when appeals are built with structured precedent is high. The problem is almost nobody's building them — the per-claim effort doesn't pencil out without a system.

That's what Stratum does. We build precedent-based denial intelligence for BH providers — documented patterns that make appeals repeatable instead of heroic. The facility keeps everything we produce regardless of whether we work together beyond the initial analysis.

Given your tenure at Sundown and your advisory role with WA DoH, I suspect you see both the clinical and operational sides of this. Happy to share what we're tracking in your market — no pitch, just the data.

Patrick Lord
Founder, Stratum Collective

Mark,

Honest question — does your team appeal PHP and IOP denials from commercial payers, or do most of them get written off?

At most BH facilities we talk to, the answer is some version of "we appeal the big ones." The small and mid-range denials get absorbed because the evidence assembly takes longer than the recovery justifies. Multiply that across a year of volume and the number is usually larger than anyone expected.

There's a structural reason it stays this way. A GAO finding confirmed that CMS isn't auditing BH prior auth denials in Medicare Advantage — which means payers face essentially no federal pressure to change their denial behavior in behavioral health. The only counterweight is provider-side evidence, and most providers don't have the infrastructure to build it efficiently.

Stratum exists to be that infrastructure. We build payer-specific denial precedent for BH providers — patterns documented so appeals go from one-off battles to repeatable recoveries.

You've been running operations at Sundown for 28 years. I'd bet you could tell me exactly which payers and denial types are the worst offenders. I'd like to compare that against what we're tracking and see if there's a fit.

Patrick Lord
Founder, Stratum Collective