Why Mental Health Claims Differ from Traditional Claims

Mental health claims have increased sharply in recent years, reflecting a sustained rise in demand for behavioral health services. Between 2019 and 2023, mental health claims rose by 83%, including an 11% increase between 2022 and 2023 alone. At the same time, more than one billion people worldwide now live with a mental health condition, underscoring the scale and persistence of behavioral health needs across populations.

As utilization grows, it has become increasingly clear that mental health claims do not follow the same patterns as traditional medical claims. They are less event-driven, more ongoing, and more influenced by access, engagement, and care delivery models. Understanding what makes mental health claims different is becoming essential for interpreting trends, evaluating utilization, and supporting sustainable outcomes.

Mental Health Claims Require Ongoing Care

Unlike many physical health claims that stem from a single, identifiable event, such as a surgery, injury, or acute episode, mental health claims are more often tied to continuous care. Treatment frequently involves recurring visits over extended periods, especially for individuals managing chronic conditions or multiple diagnoses.

This pattern shows up clearly in utilization data. Employee Benefit Research Institute (EBRI) found that individuals with a mental health condition were twice as likely to visit the emergency department three times within a six-month period and four times as likely to visit four times compared to those without a mental health condition.

Rather than reflecting a one-off crisis, these repeat visits point to ongoing care needs and unresolved or recurring challenges.

Because of this, mental health claims tend to appear in steady, repeating patterns instead of clear start-and-stop timelines. Claims activity may continue month after month, reflecting sustained treatment needs rather than a defined resolution point.

As a result, these claims require a different approach to evaluation and forecasting. Instead of focusing on isolated incidents, claims professionals must consider long-term engagement, continuity of care, and evolving utilization trends over time.

Telehealth Has Fundamentally Changed Mental Health Claims

Telehealth has reshaped mental health care delivery more dramatically than almost any other clinical category. This shift has meaningful implications for claim volume, frequency, and access. EBRI data shows that 73% of organizations now offer telehealth mental health services, signaling widespread adoption across benefit plans and care models.

But telehealth also introduces new utilization patterns. Lower barriers to entry and easier access can lead to more frequent visits, changing how and when claims appear compared to traditional in-person care.

For insurers, this means mental health claims are increasingly coming through virtual channels, often with utilization trends that look very different from those associated with facility-based or procedural care. It’s another example of why mental health claims require a different interpretive lens than traditional medical claims.

The Visibility Gap in Mental Health Claims

Coverage for mental health services is now nearly universal among large employers. According to EBRI, 97% of surveyed employers offer mental health coverage through their health plans.

But coverage doesn’t always translate into visibility. Only 22% of employers report actively tracking employee mental health utilization through claims data or reporting from health plans or administrators.

This disconnect helps explain why mental health claims can feel more difficult to interpret than other claim types. The issue isn’t whether benefits exist; it’s whether employers and plan administrators have consistent insight into how services are being accessed, how often care occurs, and how utilization trends change over time.

How Provider Networks Shape Mental Health Claims

Mental health provider networks differ significantly from physical health networks, and those differences have a direct impact on claims behavior. Fewer than half of employers report receiving or tracking common access indicators such as appointment wait times, provider-to-enrollee ratios, or geographic access standards.

Notably, only 31% of employers track out-of-network mental health utilization, even though access challenges and affordability continue to be major concerns.

When provider networks are limited or access is constrained, mental health claims are more likely to involve out-of-network care than other claim types. This adds another layer of complexity to claims evaluation, from higher costs to less predictable utilization patterns.

Engagement, Privacy, and Timing Influence Mental Health Claims

Mental health claims are heavily influenced by human factors that play a smaller role in most other areas of care. Employers report that stigma, confidentiality concerns, and limited awareness of available benefits remain some of the biggest barriers to employee engagement with mental health services.

These dynamics often delay care, push utilization into later stages, or result in more serious cases when individuals finally seek treatment. As a result, mental health claims tend to reflect when people feel comfortable accessing care, not necessarily when symptoms first appear.

This timing difference further sets mental health claims apart from traditional medical claims, where care is more often driven by immediate or visible health events.

What Makes Mental Health Claims Different

Taken together, mental health claims tend to differ from other claims in several key ways:

• They involve ongoing and recurring utilization, rather than single events
• They are heavily influenced by telehealth delivery models
• They are sensitive to network access and provider availability
• They often lack consistent utilization visibility
• They are shaped by engagement, stigma, and privacy considerations

These factors help explain why mental health claims require a different interpretive lens than traditional medical claims.

Mental Health Benefits are Evolving

The rise in mental health claims reflects a broader shift in how care is accessed and delivered. Employers are taking notice, as 85% report interest in enhancing their mental health benefits, with many exploring expanded services and additional support options to better meet employee needs (American Psychological Association).

This signals a continued evolution in mental health care, where access, engagement, and innovative delivery models will play an increasingly central role in shaping claims and supporting positive outcomes.

Looking for claims solutions that keep pace with evolving care? Connect with our team today.

Check out our sources:

American Psychological Association. 2022 Work and Well‑Being Survey: Mental Health Support in the Workplace. American Psychological Association, 2022, https://www.apa.org/pubs/reports/work-well-being/2022-mental-health-support.

Employee Benefit Research Institute. Executive Summary, EBRI_es_mentalhealthee. Employee Benefit Research Institute, 2025. PDF file, https://www.ebri.org/docs/default-source/executive-summaries/ebri_es_mentalhealthee.pdf.

Employee Benefit Research Institute. Executive Summary, EBRI_es_mentalhealther. Employee Benefit Research Institute, 2025. PDF file, https://www.ebri.org/docs/default-source/executive-summaries/ebri_es_mentalhealther.pdf.

LexisNexis Risk Solutions. “New Data Show Mental Health Claims Continue to Rise in the U.S.” LexisNexis Risk Solutions, 15 May 2024, https://risk.lexisnexis.com/about-us/press-room/press-release/20240515-mental-health-data.